hospital_name,last_updated_on,version,location_name,hospital_address,license_number|NY,type_2_npi,"To the best of its knowledge and belief, this 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 in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",attester_name,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
St Johns Riverside Hospital,3/27/2026,3.0.0,St Johns Riverside Health System|St Johns Riverside Hospital,"967 N Broadway,Yonkers,NY,10701",5907001H,1578526695,TRUE,"Sabrina Silvera, Senior Director of Revenue Cycle",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
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GHI|Carelon Commercial GHI|negotiated_algorithm,median_amount|Carelon Commercial GHI|Carelon Commercial GHI,10th_percentile|Carelon Commercial GHI|Carelon Commercial GHI,90th_percentile|Carelon Commercial GHI|Carelon Commercial GHI,count|Carelon Commercial GHI|Carelon Commercial GHI,standard_charge|Carelon Commercial GHI|Carelon Commercial GHI|methodology,additional_payer_notes|Carelon Commercial GHI|Carelon Commercial GHI,standard_charge|Carelon Medicaid|Carelon Medicaid|negotiated_dollar,standard_charge|Carelon Medicaid|Carelon Medicaid|negotiated_percentage,standard_charge|Carelon Medicaid|Carelon Medicaid|negotiated_algorithm,median_amount|Carelon Medicaid|Carelon Medicaid,10th_percentile|Carelon Medicaid|Carelon Medicaid,90th_percentile|Carelon Medicaid|Carelon Medicaid,count|Carelon Medicaid|Carelon Medicaid,standard_charge|Carelon Medicaid|Carelon Medicaid|methodology,additional_payer_notes|Carelon Medicaid|Carelon Medicaid,standard_charge|Carelon Medicare|Carelon 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Healthy Living,count|Centers Plan For Healthy Living|Centers Plan For Healthy Living,standard_charge|Centers Plan For Healthy Living|Centers Plan For Healthy Living|methodology,additional_payer_notes|Centers Plan For Healthy Living|Centers Plan For Healthy Living,standard_charge|Cigna|Cigna|negotiated_dollar,standard_charge|Cigna|Cigna|negotiated_percentage,standard_charge|Cigna|Cigna|negotiated_algorithm,median_amount|Cigna|Cigna,10th_percentile|Cigna|Cigna,90th_percentile|Cigna|Cigna,count|Cigna|Cigna,standard_charge|Cigna|Cigna|methodology,additional_payer_notes|Cigna|Cigna,standard_charge|Emblem Health|GHI|negotiated_dollar,standard_charge|Emblem Health|GHI|negotiated_percentage,standard_charge|Emblem Health|GHI|negotiated_algorithm,median_amount|Emblem Health|GHI,10th_percentile|Emblem Health|GHI,90th_percentile|Emblem Health|GHI,count|Emblem Health|GHI,standard_charge|Emblem Health|GHI|methodology,additional_payer_notes|Emblem Health|GHI,standard_charge|Emblem Health|HIP|negotiated_dollar,standard_charge|Emblem Health|HIP|negotiated_percentage,standard_charge|Emblem Health|HIP|negotiated_algorithm,median_amount|Emblem Health|HIP,10th_percentile|Emblem Health|HIP,90th_percentile|Emblem Health|HIP,count|Emblem Health|HIP,standard_charge|Emblem Health|HIP|methodology,additional_payer_notes|Emblem Health|HIP,standard_charge|Emblem Health|Select Care Network|negotiated_dollar,standard_charge|Emblem Health|Select Care Network|negotiated_percentage,standard_charge|Emblem Health|Select Care Network|negotiated_algorithm,median_amount|Emblem Health|Select Care Network,10th_percentile|Emblem Health|Select Care Network,90th_percentile|Emblem Health|Select Care Network,count|Emblem Health|Select Care Network,standard_charge|Emblem Health|Select Care Network|methodology,additional_payer_notes|Emblem Health|Select Care Network,standard_charge|Empire Blue Cross Blue Shield|Individual Network|negotiated_dollar,standard_charge|Empire Blue Cross Blue Shield|Individual Network|negotiated_percentage,standard_charge|Empire Blue Cross Blue Shield|Individual Network|negotiated_algorithm,median_amount|Empire Blue Cross Blue Shield|Individual Network,10th_percentile|Empire Blue Cross Blue Shield|Individual Network,90th_percentile|Empire Blue Cross Blue Shield|Individual Network,count|Empire Blue Cross Blue Shield|Individual Network,standard_charge|Empire Blue Cross Blue Shield|Individual Network|methodology,additional_payer_notes|Empire Blue Cross Blue Shield|Individual Network,standard_charge|Empire Blue Cross Blue Shield HealthPlus Medicaid|Empire Blue Cross Blue Shield HealthPlus Medicaid|negotiated_dollar,standard_charge|Empire Blue Cross Blue Shield HealthPlus Medicaid|Empire Blue Cross Blue Shield HealthPlus Medicaid|negotiated_percentage,standard_charge|Empire Blue Cross Blue Shield HealthPlus Medicaid|Empire Blue Cross Blue Shield HealthPlus Medicaid|negotiated_algorithm,median_amount|Empire Blue Cross Blue Shield HealthPlus Medicaid|Empire Blue Cross Blue Shield HealthPlus Medicaid,10th_percentile|Empire Blue Cross Blue Shield HealthPlus Medicaid|Empire Blue Cross Blue Shield HealthPlus Medicaid,90th_percentile|Empire Blue Cross Blue Shield HealthPlus Medicaid|Empire Blue Cross Blue Shield HealthPlus Medicaid,count|Empire Blue Cross Blue Shield HealthPlus Medicaid|Empire Blue Cross Blue Shield HealthPlus Medicaid,standard_charge|Empire Blue Cross Blue Shield HealthPlus Medicaid|Empire Blue Cross Blue Shield HealthPlus Medicaid|methodology,additional_payer_notes|Empire Blue Cross Blue Shield HealthPlus Medicaid|Empire Blue Cross Blue Shield HealthPlus Medicaid,standard_charge|Empire Blue Cross Blue Shield Indemnity|Empire Blue Cross Blue Shield Indemnity|negotiated_dollar,standard_charge|Empire Blue Cross Blue Shield Indemnity|Empire Blue Cross Blue Shield Indemnity|negotiated_percentage,standard_charge|Empire Blue Cross Blue Shield Indemnity|Empire Blue Cross Blue Shield 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Essential|negotiated_algorithm,median_amount|Empire Blue Cross Blue Shield Medicaid Essential|Empire Blue Cross Blue Shield Medicaid Essential,10th_percentile|Empire Blue Cross Blue Shield Medicaid Essential|Empire Blue Cross Blue Shield Medicaid Essential,90th_percentile|Empire Blue Cross Blue Shield Medicaid Essential|Empire Blue Cross Blue Shield Medicaid Essential,count|Empire Blue Cross Blue Shield Medicaid Essential|Empire Blue Cross Blue Shield Medicaid Essential,standard_charge|Empire Blue Cross Blue Shield Medicaid Essential|Empire Blue Cross Blue Shield Medicaid Essential|methodology,additional_payer_notes|Empire Blue Cross Blue Shield Medicaid Essential|Empire Blue Cross Blue Shield Medicaid Essential,standard_charge|Empire Blue Cross Blue Shield PPO|Empire Blue Cross Blue Shield PPO|negotiated_dollar,standard_charge|Empire Blue Cross Blue Shield PPO|Empire Blue Cross Blue Shield PPO|negotiated_percentage,standard_charge|Empire Blue Cross Blue Shield PPO|Empire Blue Cross Blue Shield PPO|negotiated_algorithm,median_amount|Empire Blue Cross Blue Shield PPO|Empire Blue Cross Blue Shield PPO,10th_percentile|Empire Blue Cross Blue Shield PPO|Empire Blue Cross Blue Shield PPO,90th_percentile|Empire Blue Cross Blue Shield PPO|Empire Blue Cross Blue Shield PPO,count|Empire Blue Cross Blue Shield PPO|Empire Blue Cross Blue Shield PPO,standard_charge|Empire Blue Cross Blue Shield PPO|Empire Blue Cross Blue Shield PPO|methodology,additional_payer_notes|Empire Blue Cross Blue Shield PPO|Empire Blue Cross Blue Shield PPO,standard_charge|Empire HMO|Empire HMO|negotiated_dollar,standard_charge|Empire HMO|Empire HMO|negotiated_percentage,standard_charge|Empire HMO|Empire HMO|negotiated_algorithm,median_amount|Empire HMO|Empire HMO,10th_percentile|Empire HMO|Empire HMO,90th_percentile|Empire HMO|Empire HMO,count|Empire HMO|Empire HMO,standard_charge|Empire HMO|Empire HMO|methodology,additional_payer_notes|Empire HMO|Empire 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Plans|negotiated_dollar,standard_charge|MetroPlus|Essential Plans|negotiated_percentage,standard_charge|MetroPlus|Essential Plans|negotiated_algorithm,median_amount|MetroPlus|Essential Plans,10th_percentile|MetroPlus|Essential Plans,90th_percentile|MetroPlus|Essential Plans,count|MetroPlus|Essential Plans,standard_charge|MetroPlus|Essential Plans|methodology,additional_payer_notes|MetroPlus|Essential Plans,standard_charge|MetroPlus Gold|MetroPlus Gold|negotiated_dollar,standard_charge|MetroPlus Gold|MetroPlus Gold|negotiated_percentage,standard_charge|MetroPlus Gold|MetroPlus Gold|negotiated_algorithm,median_amount|MetroPlus Gold|MetroPlus Gold,10th_percentile|MetroPlus Gold|MetroPlus Gold,90th_percentile|MetroPlus Gold|MetroPlus Gold,count|MetroPlus Gold|MetroPlus Gold,standard_charge|MetroPlus Gold|MetroPlus Gold|methodology,additional_payer_notes|MetroPlus Gold|MetroPlus Gold,standard_charge|MetroPlus Medicare Advantage|MetroPlus Medicare Advantage|negotiated_dollar,standard_charge|MetroPlus Medicare Advantage|MetroPlus Medicare Advantage|negotiated_percentage,standard_charge|MetroPlus Medicare Advantage|MetroPlus Medicare Advantage|negotiated_algorithm,median_amount|MetroPlus Medicare Advantage|MetroPlus Medicare Advantage,10th_percentile|MetroPlus Medicare Advantage|MetroPlus Medicare Advantage,90th_percentile|MetroPlus Medicare Advantage|MetroPlus Medicare Advantage,count|MetroPlus Medicare Advantage|MetroPlus Medicare Advantage,standard_charge|MetroPlus Medicare Advantage|MetroPlus Medicare Advantage|methodology,additional_payer_notes|MetroPlus Medicare Advantage|MetroPlus Medicare Advantage,standard_charge|Molina Healthcare of New York|Essential Plans|negotiated_dollar,standard_charge|Molina Healthcare of New York|Essential Plans|negotiated_percentage,standard_charge|Molina Healthcare of New York|Essential Plans|negotiated_algorithm,median_amount|Molina Healthcare of New York|Essential Plans,10th_percentile|Molina Healthcare of New York|Essential Plans,90th_percentile|Molina Healthcare of New York|Essential Plans,count|Molina Healthcare of New York|Essential Plans,standard_charge|Molina Healthcare of New York|Essential Plans|methodology,additional_payer_notes|Molina Healthcare of New York|Essential Plans,standard_charge|Molina Healthcare of New York|Exchange|negotiated_dollar,standard_charge|Molina Healthcare of New York|Exchange|negotiated_percentage,standard_charge|Molina Healthcare of New York|Exchange|negotiated_algorithm,median_amount|Molina Healthcare of New York|Exchange,10th_percentile|Molina Healthcare of New York|Exchange,90th_percentile|Molina Healthcare of New York|Exchange,count|Molina Healthcare of New York|Exchange,standard_charge|Molina Healthcare of New York|Exchange|methodology,additional_payer_notes|Molina Healthcare of New York|Exchange,standard_charge|Molina Healthcare of New York|Medicaid|negotiated_dollar,standard_charge|Molina Healthcare of New 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BHS|Medicaid,90th_percentile|MVP BHS|Medicaid,count|MVP BHS|Medicaid,standard_charge|MVP BHS|Medicaid|methodology,additional_payer_notes|MVP BHS|Medicaid,standard_charge|MVP BHS|Medicare|negotiated_dollar,standard_charge|MVP BHS|Medicare|negotiated_percentage,standard_charge|MVP BHS|Medicare|negotiated_algorithm,median_amount|MVP BHS|Medicare,10th_percentile|MVP BHS|Medicare,90th_percentile|MVP BHS|Medicare,count|MVP BHS|Medicare,standard_charge|MVP BHS|Medicare|methodology,additional_payer_notes|MVP BHS|Medicare,standard_charge|MVP Commercial|MVP Commercial|negotiated_dollar,standard_charge|MVP Commercial|MVP Commercial|negotiated_percentage,standard_charge|MVP Commercial|MVP Commercial|negotiated_algorithm,median_amount|MVP Commercial|MVP Commercial,10th_percentile|MVP Commercial|MVP Commercial,90th_percentile|MVP Commercial|MVP Commercial,count|MVP Commercial|MVP Commercial,standard_charge|MVP Commercial|MVP Commercial|methodology,additional_payer_notes|MVP Commercial|MVP 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Plan,10th_percentile|MVP Individual Exchange.Student Health Plan|MVP Individual Exchange.Student Health Plan,90th_percentile|MVP Individual Exchange.Student Health Plan|MVP Individual Exchange.Student Health Plan,count|MVP Individual Exchange.Student Health Plan|MVP Individual Exchange.Student Health Plan,standard_charge|MVP Individual Exchange.Student Health Plan|MVP Individual Exchange.Student Health Plan|methodology,additional_payer_notes|MVP Individual Exchange.Student Health Plan|MVP Individual Exchange.Student Health Plan,standard_charge|Oscar|Commercial|negotiated_dollar,standard_charge|Oscar|Commercial|negotiated_percentage,standard_charge|Oscar|Commercial|negotiated_algorithm,median_amount|Oscar|Commercial,10th_percentile|Oscar|Commercial,90th_percentile|Oscar|Commercial,count|Oscar|Commercial,standard_charge|Oscar|Commercial|methodology,additional_payer_notes|Oscar|Commercial,standard_charge|Oscar|Medicare|negotiated_dollar,standard_charge|Oscar|Medicare|negotiated_percentage,standard_charge|Oscar|Medicare|negotiated_algorithm,median_amount|Oscar|Medicare,10th_percentile|Oscar|Medicare,90th_percentile|Oscar|Medicare,count|Oscar|Medicare,standard_charge|Oscar|Medicare|methodology,additional_payer_notes|Oscar|Medicare,standard_charge|Partners Health Plan|Dually Enrolled|negotiated_dollar,standard_charge|Partners Health Plan|Dually Enrolled|negotiated_percentage,standard_charge|Partners Health Plan|Dually Enrolled|negotiated_algorithm,median_amount|Partners Health Plan|Dually Enrolled,10th_percentile|Partners Health Plan|Dually Enrolled,90th_percentile|Partners Health Plan|Dually Enrolled,count|Partners Health Plan|Dually Enrolled,standard_charge|Partners Health Plan|Dually Enrolled|methodology,additional_payer_notes|Partners Health Plan|Dually Enrolled,standard_charge|Partners Health Plan|Medicaid|negotiated_dollar,standard_charge|Partners Health Plan|Medicaid|negotiated_percentage,standard_charge|Partners Health Plan|Medicaid|negotiated_algorithm,median_amount|Partners Health Plan|Medicaid,10th_percentile|Partners Health Plan|Medicaid,90th_percentile|Partners Health Plan|Medicaid,count|Partners Health Plan|Medicaid,standard_charge|Partners Health Plan|Medicaid|methodology,additional_payer_notes|Partners Health Plan|Medicaid,standard_charge|United Behavioral Health of NY IPA|United Behavioral Health of NY IPA|negotiated_dollar,standard_charge|United Behavioral Health of NY IPA|United Behavioral Health of NY IPA|negotiated_percentage,standard_charge|United Behavioral Health of NY IPA|United Behavioral Health of NY IPA|negotiated_algorithm,median_amount|United Behavioral Health of NY IPA|United Behavioral Health of NY IPA,10th_percentile|United Behavioral Health of NY IPA|United Behavioral Health of NY IPA,90th_percentile|United Behavioral Health of NY IPA|United Behavioral Health of NY IPA,count|United Behavioral Health of NY IPA|United Behavioral Health of NY IPA,standard_charge|United Behavioral Health of NY IPA|United Behavioral Health of NY IPA|methodology,additional_payer_notes|United Behavioral Health of NY IPA|United Behavioral Health of NY IPA,standard_charge|United Healthcare|Oxford OX|negotiated_dollar,standard_charge|United Healthcare|Oxford OX|negotiated_percentage,standard_charge|United Healthcare|Oxford OX|negotiated_algorithm,median_amount|United Healthcare|Oxford OX,10th_percentile|United Healthcare|Oxford OX,90th_percentile|United Healthcare|Oxford OX,count|United Healthcare|Oxford OX,standard_charge|United Healthcare|Oxford OX|methodology,additional_payer_notes|United Healthcare|Oxford OX,standard_charge|United Healthcare|Oxford PA|negotiated_dollar,standard_charge|United Healthcare|Oxford PA|negotiated_percentage,standard_charge|United Healthcare|Oxford PA|negotiated_algorithm,median_amount|United Healthcare|Oxford PA,10th_percentile|United Healthcare|Oxford PA,90th_percentile|United Healthcare|Oxford PA,count|United Healthcare|Oxford PA,standard_charge|United Healthcare|Oxford PA|methodology,additional_payer_notes|United Healthcare|Oxford PA,standard_charge|Village Caremax|Village Caremax|negotiated_dollar,standard_charge|Village Caremax|Village Caremax|negotiated_percentage,standard_charge|Village Caremax|Village Caremax|negotiated_algorithm,median_amount|Village Caremax|Village Caremax,10th_percentile|Village Caremax|Village Caremax,90th_percentile|Village Caremax|Village Caremax,count|Village Caremax|Village Caremax,standard_charge|Village Caremax|Village Caremax|methodology,additional_payer_notes|Village Caremax|Village Caremax,standard_charge|VNS Choice|VNS Choice|negotiated_dollar,standard_charge|VNS Choice|VNS Choice|negotiated_percentage,standard_charge|VNS Choice|VNS Choice|negotiated_algorithm,median_amount|VNS Choice|VNS Choice,10th_percentile|VNS Choice|VNS Choice,90th_percentile|VNS Choice|VNS Choice,count|VNS Choice|VNS Choice,standard_charge|VNS Choice|VNS Choice|methodology,additional_payer_notes|VNS Choice|VNS Choice,standard_charge|Wellcare|Wellcare|negotiated_dollar,standard_charge|Wellcare|Wellcare|negotiated_percentage,standard_charge|Wellcare|Wellcare|negotiated_algorithm,median_amount|Wellcare|Wellcare,10th_percentile|Wellcare|Wellcare,90th_percentile|Wellcare|Wellcare,count|Wellcare|Wellcare,standard_charge|Wellcare|Wellcare|methodology,additional_payer_notes|Wellcare|Wellcare,standard_charge|min,standard_charge|max,additional_generic_notes,billing_class
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,998,MS-DRG,120,RC,,,,inpatient,,,,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Principal Diagnosis Invalid as Discharge Diagnosis,,,,0,other,Principal Diagnosis Invalid as Discharge Diagnosis + No services performed during 15-month lookback period,1475,5834,,facility
UNGROUPABLE,999,MS-DRG,120,RC,,,,inpatient,,,,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Ungroupable,,,,0,other,Ungroupable + No services performed during 15-month lookback period,1475,5834,,facility
GROUP PSYCHOTHERAPY,90853,CPT,915,RC,,,,outpatient,,,482,409.7,,70,,35,35,35,338,percent of total billed charges,,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,106.81,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,82,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,82,,,,,,,case rate,,155,,,,,,,case rate,,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,119.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,107.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,68.09,68.09,68.09,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,523.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,14.69,14.69,14.69,12,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,444.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,132.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,82,3783,,professional
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,263,223.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ALLG SPEC IGE CRUDE XTRC EA,86003,CPT,302,RC,,,,outpatient,,,63,53.55,,70,,70,7,308,135,percent of total billed charges,,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.03,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,12.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,12.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,36.9,36.9,36.9,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18.1,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.22,,,,,,,fee schedule,,4.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,5.22,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,36.5,3.65,36.5,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,129.15,129.15,129.15,35,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,18.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,5.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.26,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.26,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.96,3783,,facility
HPYLORI STOOL AG IA,87338,CPT,306,RC,,,,outpatient,,,170,144.5,,70,,20,20,20,1 through 10,percent of total billed charges,,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57.84,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,33.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,33.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,10.54,10.54,10.54,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,49.91,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.38,,,,,,,fee schedule,,13.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,14.38,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,8.03,8.03,8.03,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,50.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,15.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.26,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17.26,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.66,3783,,facility
ASSAY OF VOLATILES,84600,CPT,301,RC,,,,outpatient,,,183,155.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,65.73,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,39.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,39.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,55.78,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.11,,,,,,,fee schedule,,16.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,17.11,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,71.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,60.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,17.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.53,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20.53,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16.25,3783,,facility
OFFICE O/P EST LOW 20 MIN,99213,CPT,510,RC,,,,outpatient,,,569,483.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,164.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,61.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,55.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,235.66,235.66,291.82,12,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,188.53,143.47,233.46,14,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,184.78,176.06,416.9,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,68.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,328.75,328.75,388.42,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,389.48,146.98,407.52,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,269.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,347.96,347.96,387.69,22,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,228.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,68.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.16,3783,,facility
AUDIT/DAST 15-30 MIN,99408,CPT,914,RC,,,,outpatient,,,616,523.6,,70,,40,40,40,1 through 10,percent of total billed charges,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,164.13,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,164.13,3783,,professional
OFFICE O/P EST MOD 30 MIN,99214,CPT,510,RC,,,,outpatient,,,723,614.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,242.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,81.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,90.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,81.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,194.99,194.99,194.99,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,146.48,146.48,156.48,15,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,167.5,157.33,407.81,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,100.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,385.92,385.92,424.19,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,389.48,380.38,396.94,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,396.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,336.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,100.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,81.24,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,2691,2287.35,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,374,317.9,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,723,614.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
GUIDE WIRE,C1769,HCPCS,278,RC,,,,outpatient,,,115,97.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,1208,1026.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
IMPLANT BREAST SILICONE/EQ,L8600,HCPCS,278,RC,,,,outpatient,,,2027,1722.95,,70,,1754.4,1754.4,1754.4,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1890.4,750,3450.4,13,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2801.83,2801.83,2801.83,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,668,567.8,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,9922,8433.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,620,527,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,530,450.5,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,497,422.45,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,2294,1949.9,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,2693,2289.05,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,3492,2968.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,162,137.7,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1476,1254.6,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,7579,6442.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,477,405.45,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,,,,outpatient,,,827,702.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,2371.2,750,2371.2,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,663,563.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,657,558.45,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,625,531.25,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1196,1016.6,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
GUIDE WIRE,C1769,HCPCS,278,RC,,,,outpatient,,,398,338.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,651,553.35,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,567,481.95,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,6796,5776.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,99,84.15,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,311,264.35,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,,,,outpatient,,,3618,3075.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,2371.2,750,2371.2,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,5469,4648.65,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,3596,3056.6,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,942,800.7,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1456,1237.6,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,469,398.65,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,475,403.75,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,613,521.05,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,580,493,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,446,379.1,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1143,971.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,2828,2403.8,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,2894,2459.9,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1088,924.8,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,927,787.95,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,662,562.7,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,583,495.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,5590,4751.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1256,1067.6,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1592,1353.2,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,759,645.15,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,724,615.4,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,506,430.1,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,487,413.95,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
KIT LEAD PNE TRIAL 41CM 10MM,02714338,CDM,270,RC,,,,outpatient,,,689,585.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,606,515.1,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,905,769.25,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,175,148.75,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,2783,2365.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,3072,2611.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1382,1174.7,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,696,591.6,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1053,895.05,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,377,320.45,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1335,1134.75,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,493,419.05,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
GUIDE WIRE,C1769,HCPCS,278,RC,,,,outpatient,,,703,597.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,508,431.8,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"IMPLANT/INSERT DEVICE, NOC",C1889,HCPCS,278,RC,,,,outpatient,,,384,326.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1588.8,1588.8,1588.8,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
IMPLANT BREAST SILICONE/EQ,L8600,HCPCS,278,RC,,,,outpatient,,,1838,1562.3,,70,,1754.4,1754.4,1754.4,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1890.4,750,3450.4,13,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2801.83,2801.83,2801.83,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1002,851.7,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1483,1260.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,451,383.35,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,288,244.8,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"CATH, HEMODIALYSIS,LONG-TERM",C1750,HCPCS,278,RC,,,,outpatient,,,393,334.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,208.56,208.56,208.56,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,500.4,500.4,500.4,17,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
IMPLANT BREAST SILICONE/EQ,L8600,HCPCS,278,RC,,,,outpatient,,,1930,1640.5,,70,,1754.4,1754.4,1754.4,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1890.4,750,3450.4,13,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2801.83,2801.83,2801.83,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1032,877.2,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,163,138.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1544,1312.4,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,774,657.9,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,3113,2646.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,,,,outpatient,,,1882,1599.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1230,1045.5,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ABDOMINLOPHASTY,01221013,CDM,360,RC,,,,outpatient,,,4481,3808.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3174,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,683,580.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,861,731.85,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1862,1582.7,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,104,88.4,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1377,1170.45,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
AMNIOEXCEL BIODEXCEL 1SQ CM,Q4137,HCPCS,278,RC,,,,outpatient,,,300,255,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1192,1013.2,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
UNLISTED URINALYSIS PX,81099,CPT,300,RC,,,,outpatient,,,371,315.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,50,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,50,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
SIGN LANG/INTERPRETER/15 MIN,T1013,HCPCS,450,RC,,,,outpatient,,,56,47.6,826,,,,,,,case rate,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,813,1548,,facility
PRIMATRIX,Q4110,HCPCS,278,RC,,,,outpatient,,,700,595,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
PURAPLY AM 1 SQ CM,Q4196,HCPCS,278,RC,,,,outpatient,,,385,327.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,895.84,895.84,1293.6,24,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
PURAPLY AM 1 SQ CM,Q4196,HCPCS,278,RC,,,,outpatient,,,509,432.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,895.84,895.84,1293.6,24,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
OASIS BURN MATRIX,Q4103,HCPCS,278,RC,,,,outpatient,,,34,28.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
ADMN SARSCOV2 VAC 1/ONLY CMP,90480,CPT,771,RC,,,,outpatient,,,126,107.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,128.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,100.3,100.3,118,1 through 10,percent of total billed charges,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,47.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,42.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,209.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,177.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.91,3783,,facility
GUIDE WIRE,C1769,HCPCS,278,RC,,,,outpatient,,,76,64.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PRIMATRIX,Q4110,HCPCS,278,RC,,,,outpatient,,,950,807.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
PRIMATRIX,Q4110,HCPCS,278,RC,,,,outpatient,,,800,680,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
PURAPLY AM 1 SQ CM,Q4196,HCPCS,278,RC,,,,outpatient,,,735,624.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,895.84,895.84,1293.6,24,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
VASC EMBOLIZE/OCCLUDE ORGAN,37243,CPT,361,RC,,,,outpatient,,,40494,34419.9,1648,,,,,,,fee schedule,,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18082,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4335,,,,,,,fee schedule,,4335,,,,,,,fee schedule,,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13622.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15056.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59510.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,50476.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,15056.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11505,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11505,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,59510.25,,facility
X-RAY EXAM OF KNEE 3,73562,CPT,320,RC,,,,outpatient,,,440,374,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.4,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,296.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,318.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,242.45,,,,,,,fee schedule,,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,91.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,102.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,91.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,113.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,448.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,380.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,113.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,91.88,3783,,facility
MED NUTRITION INDIV SUBSEQ,97803,CPT,942,RC,,,,outpatient,,,49,41.65,,70,,88,88,88,1 through 10,percent of total billed charges,,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,106,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,285.02,285.02,285.02,1 through 10,percent of total billed charges,,62.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,166.6,127.4,166.6,16,percent of total billed charges,,49,,,,,,,fee schedule,,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,23.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,20.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,106.76,106.76,106.76,124,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,101.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,86.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,25.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,156,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,154,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.88,3783,,facility
YPL-DOT/NON-DOT BREATH AL TEST,08030167,CDM,940,RC,,,,outpatient,,,45,38.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1037,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1037,3783,,facility
ASSAY NEPHELOMETRY NOT SPEC,83883,CPT,301,RC,,,,outpatient,,,308,261.8,,70,,48,32,48,33,percent of total billed charges,,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.2,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,31.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,31.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47.18,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.6,,,,,,,fee schedule,,12.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,13.6,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,35.7,35.7,35.7,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,56.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,47.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,14.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16.32,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16.32,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.92,3783,,facility
ALPHA-1-ANTITRYPSIN PHENO,82104,CPT,309,RC,,,,outpatient,,,186,158.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59.16,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,33.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,33.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,50.19,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.46,,,,,,,fee schedule,,13.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,14.46,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,50.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,15.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.74,3783,,facility
UNLISTED PX CLIN BRACHYTX,77799,CPT,333,RC,,,,outpatient,,,11341,9639.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19004,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,339.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,120.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,107.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,133.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,525.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,446.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,133.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1024,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.73,19004,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,3570,3034.5,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,9173,7797.05,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1341,1139.85,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
TRLUML BALO ANGIOP 1ST VEIN,37248,CPT,320,RC,,,,outpatient,,,19616,16673.6,8911,,,,,,,case rate,,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19371.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,20856.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1041.61,,,,,,,fee schedule,,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6009.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,6716.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,6009.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7423.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7126,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,7554,,,,,,,case rate,,7423.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1041.61,20856.15,,facility
DRUG ASSAY CYCLOSPORINE,80158,CPT,301,RC,,,,outpatient,,,155,131.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.62,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,41.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,41.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,62.61,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.05,,,,,,,fee schedule,,17.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,18.05,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,74.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,63.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,18.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.66,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21.66,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.15,3783,,facility
COLD LASER FIRST VISIT,01601009,CDM,460,RC,,,,outpatient,,,200,170,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 268.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 268.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1241,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1047,889.95,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,236,200.6,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,3258,2769.3,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,479,407.15,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
MEDICAL NUTRITION GROUP,97804,CPT,942,RC,,,,outpatient,,,108,91.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.51,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,35.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.23,,,,,,,fee schedule,,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,13.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,11.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,48.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,14.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,156,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,154,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.79,3783,,facility
"CATH, DRAINAGE",C1729,HCPCS,278,RC,,,,outpatient,,,587,498.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CT HRT W/O DYE W/CA TEST,75571,CPT,350,RC,,,,outpatient,,,250,212.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,296.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,318.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,91.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,102.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,91.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,250,250,250,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,113.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,82.17,82.17,82.17,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,448.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,380.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,113.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,91.89,3783,,facility
MEDICAL NUTRITION INDIV IN,97802,CPT,942,RC,,,,outpatient,,,49,41.65,,70,,88,88,88,36,percent of total billed charges,,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,106,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,336.91,336.91,336.91,12,percent of total billed charges,,74.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,166.6,156,166.6,20,percent of total billed charges,,49,,,,,,,fee schedule,,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,27.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,24.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,149.6,149.6,149.6,16,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,119.68,119.68,119.68,92,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,99.6,99.6,99.6,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,121.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,103.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,30.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,156,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,154,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.97,3783,,facility
YPL- ADULTERATION(DILUTION)URI,08030169,CDM,940,RC,,,,outpatient,,,15,12.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1037,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1037,3783,,facility
COMPOSITE DRSG <= 16 SQ IN,A6203,HCPCS,623,RC,,,,outpatient,,,24,20.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
OASIS BURN MATRIX,Q4103,HCPCS,278,RC,,,,outpatient,,,23,19.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
PURAPLY XT 1 SQ CM,Q4197,HCPCS,278,RC,,,,outpatient,,,181,153.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
"INTRO/SHEATH, NON-LASER",C1894,HCPCS,278,RC,,,,outpatient,,,98,83.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1074,912.9,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,,,,outpatient,,,2606,2215.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,2371.2,750,2371.2,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,8574,7287.9,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,255,216.75,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
COLD LASER BOOSTER TREAMENT,03299351,CDM,510,RC,,,,outpatient,,,100,85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,3783,,facility
COLD LASER BOOSTER TREAMENT,01601012,CDM,942,RC,,,,outpatient,,,100,85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",156,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,154,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",154,3783,,facility
IMPLANT BREAST SILICONE/EQ,L8600,HCPCS,278,RC,,,,outpatient,,,2606,2215.1,,70,,1754.4,1754.4,1754.4,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1890.4,750,3450.4,13,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2801.83,2801.83,2801.83,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,9316,7918.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
EDU&TRN PT SELF-MGMT NQHP 1,98960,CPT,942,RC,,,,outpatient,,,50,42.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",148.12,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",156,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,154,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",148.12,3783,,facility
US TRANSRECTAL,76872,CPT,402,RC,,,,outpatient,,,909,772.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,458.73,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,497.03,,,,,,,fee schedule,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,624,530.4,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
GUIDE WIRE,C1769,HCPCS,278,RC,,,,outpatient,,,373,317.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,2436,2070.6,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
COLD LASER FALOW UP VST BOOSTE,01601010,CDM,460,RC,,,,outpatient,,,100,85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 268.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 268.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1241,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,3204,2723.4,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
COLD LASER INITIAL TREATMENT,03299350,CDM,510,RC,,,,outpatient,,,200,170,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,3783,,facility
COLD LASER INITIAL TREATMENT,01601013,CDM,942,RC,,,,outpatient,,,200,170,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",156,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,154,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",154,3783,,facility
STRAPPING OF HAND OR FINGER,29280,CPT,450,RC,,,,outpatient,,,229,194.65,826,,,,,,,case rate,,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,69.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,76.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,257.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,76.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,69.62,1548,,facility
GUIDE WIRE,C1769,HCPCS,272,RC,,,,outpatient,,,191,162.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
APLIGRAF,Q4101,HCPCS,278,RC,,,,outpatient,,,91,77.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,17088,14524.8,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,143,121.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1323,1124.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
AMBULATORY SURGICAL BOOT EAC,L3260,HCPCS,270,RC,,,,outpatient,,,229,194.65,,70,,87.2,87.2,87.2,1 through 10,percent of total billed charges,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,2538,2157.3,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,1263,1073.55,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
"INTRO/SHEATH, NON-LASER",C1894,HCPCS,278,RC,,,,outpatient,,,263,223.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
OASIS WOUND MATRIX,Q4102,HCPCS,278,RC,,,,outpatient,,,34,28.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
Transderm Scop,10019055303A,NDC,250,RC,,,,inpatient,1,UN  ,12.63,10.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
"TRANSFER DEVICE, CLOSED SYSTEM 1 EA",0269935233031000078,CDM,250,RC,,,,inpatient,1,EA,5.37,4.56,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Desitin Diaper Rash,74300000070A,NDC,250,RC,,,,inpatient,1,EA,4.5,3.83,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
fluPHENAZine Decanoate,63323027205,NDC,250,RC,,,,inpatient,25,ML,8.23,7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tolnaftate,00536132926A,NDC,250,RC,,,,inpatient,1,EA,3.66,3.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Omnipaque 12,00407141612,NDC,250,RC,,,,inpatient,500,ML,114.24,97.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mupirocin,45802011222,NDC,250,RC,,,,inpatient,1,EA,8.54,7.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Safetussin DM,53076011112A,NDC,250,RC,,,,inpatient,5,ML,0.3,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Descovy,61958200201,NDC,250,RC,,,,inpatient,1,EA,71.21,60.53,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hibiclens,00234057508A,NDC,250,RC,,,,inpatient,1,EA,2.78,2.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Losartan Potassium-hydroCHLOROthiazide,43547042309A,NDC,250,RC,,,,inpatient,1,EA,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mag-Al Plus,00121176130B,NDC,250,RC,,,,inpatient,5,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tarka,00074329013,NDC,250,RC,,,,inpatient,1,EA,1.29,1.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Potassium Chloride,63304007601A,NDC,250,RC,,,,inpatient,10,UN  ,0.31,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tubersol,49281075222,NDC,250,RC,,,,inpatient,5,UN  ,6.39,5.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prezista,59676056501,NDC,250,RC,,,,inpatient,100,ML,5.82,4.95,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gelfoam,00009043304,NDC,250,RC,,,,inpatient,1,GM,44.87,38.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Polyethylene Glycol 3350,45802086802A,NDC,250,RC,,,,inpatient,255,GM,11.69,9.94,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Brimonidine Tartrate,61314014405A,NDC,250,RC,,,,inpatient,1,EA,124.9,106.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amoxicillin/Clavulanate Potassium,00781185201,NDC,250,RC,,,,inpatient,1,EA,0.45,0.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Butorphanol Tartrate,00409162301,NDC,250,RC,,,,inpatient,1,ML,3.54,3.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calcium Gluconate-Sodium Chloride,44567062024,NDC,250,RC,,,,inpatient,1,GM,8.2,6.97,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ferrous Sulfate,54838001150A,NDC,250,RC,,,,inpatient,15,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Stalevo 100,52427081601,NDC,250,RC,,,,inpatient,1,EA,3.09,2.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Famotidine,00641602225,NDC,250,RC,,,,inpatient,10,ML,0.41,0.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Omnipaque 300,00407141372A,NDC,250,RC,,,,inpatient,30,ML,44.84,38.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Oxymetazoline HCl,45802041059a,NDC,250,RC,,,,inpatient,1,EA,0.54,0.46,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluocinonide,51672126401A,NDC,250,RC,,,,inpatient,1,EA,27.56,23.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cefoTEtan disodium,63323038620,NDC,250,RC,,,,inpatient,2,GM,16.59,14.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lovenox,00075062280A,NDC,250,RC,,,,inpatient,80,ML,6.25,5.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
miSOPROStol,70954044310A,NDC,250,RC,,,,inpatient,100,GM,0.85,0.72,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amoxicillin/Clavulanate Potassium,43598020451A,NDC,250,RC,,,,inpatient,250,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Piperacillin and Tazobactam,00781311395A,NDC,250,RC,,,,inpatient,3.375,GM,2.73,2.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Daliresp,00310008839,NDC,250,RC,,,,inpatient,250,GM,9.13,7.76,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00409202902C,NDC,250,RC,,,,inpatient,51,ML,100,85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Daliresp,00310009530A,NDC,250,RC,,,,inpatient,500,GM,0.48,0.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nafcillin,63323032710A,NDC,250,RC,,,,inpatient,1,GM,11.18,9.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Healthylax Polyethylene Glycol 3350,60687043192,NDC,250,RC,,,,inpatient,17,GM,0.96,0.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
White Petrolatum,00168005321,NDC,250,RC,,,,inpatient,1,EA,1.07,0.91,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Triple Antibiotic,00713026831A,NDC,250,RC,,,,inpatient,1,EA,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Kerr Insta-Char,66689020304A,NDC,250,RC,,,,inpatient,25,GM,10.16,8.64,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Santyl,50484001030,NDC,250,RC,,,,inpatient,1,EA,279.23,237.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin A&D,00168003501A,NDC,250,RC,,,,inpatient,1,EA,1.11,0.94,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Infuvite,54643564901,NDC,250,RC,,,,inpatient,10,ML,7.09,6.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BUPivacaine HCl,00409116501B,NDC,250,RC,,,,inpatient,50,ML,31.46,26.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cycloPHOSphamide,10019095701,NDC,636,RC,J9074,HCPCS,,outpatient,2000,ML,500.66,425.56,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.26,3783,,facility
Clotrimazole,61269022063A,NDC,250,RC,,,,inpatient,1,EA,2.57,2.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Selenium Sulfide,45802004064,NDC,250,RC,,,,inpatient,1,EA,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
lamiVUDine-zidovudine,31722050660A,NDC,250,RC,,,,inpatient,1,EA,10.73,9.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Silvadene,61570013140A,NDC,250,RC,,,,inpatient,1,EA,11.46,9.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PILL CUTTER ORIG 1 EACH,0270026825715067015,CDM,250,RC,,,,inpatient,1,EA,3.71,3.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nitrofurantoin Monohydrate/Macrocrystals,00185012201,NDC,250,RC,,,,inpatient,100,ML,2.05,1.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pramipexole Dihydrochloride,13668009190,NDC,250,RC,,,,inpatient,0.125,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Isoniazid,46287000901,NDC,250,RC,,,,inpatient,10,ML,0.59,0.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
fosfomycin tromethamine,70700026894A,NDC,250,RC,,,,inpatient,3,GM,38.32,32.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Genvoya,61958190101,NDC,250,RC,,,,inpatient,1,EA,128.73,109.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sore Throat Lozenges,00904625549A,NDC,250,RC,,,,inpatient,1,EA,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
diphenoxylate HCl-atropine sulfate,62559049010A,NDC,250,RC,,,,inpatient,1,EA,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Flow-Eze Vented,63323090490,NDC,250,RC,,,,inpatient,1,EA,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amoxicillin/Clavulanate Potassium,66685101201,NDC,250,RC,,,,inpatient,400,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nafcillin,63323032820A,NDC,250,RC,,,,inpatient,2,GM,5.64,4.79,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Recombivax HB,00006499200,NDC,250,RC,,,,inpatient,40,GM,162.24,137.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Banatrol Plus,94688008470,NDC,250,RC,,,,inpatient,1,EA,1.08,0.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bacitracin,00904702367A,NDC,250,RC,,,,inpatient,0.9,GM,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Miconazole 7,61269073063A,NDC,250,RC,,,,inpatient,1,EA,5.32,4.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Provayblue,00517037405,NDC,636,RC,Q9968,HCPCS,,outpatient,50,ML,189.67,161.22,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,10.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.76,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.76,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.76,3783,,facility
Quelicin,00409662902A,NDC,250,RC,,,,inpatient,200,ML,21.08,17.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluocinonide,00093026292A,NDC,250,RC,,,,inpatient,1,EA,34.21,29.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calcipotriene,68462050165A,NDC,250,RC,,,,inpatient,1,EA,57.56,48.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hurricaine One,00283061011A,NDC,250,RC,,,,inpatient,1,EA,3.67,3.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
"TRANSFER DEVICE, CLOSED SYSTEM 1 EA",0269935033031000003,CDM,250,RC,,,,inpatient,1,EA,5.37,4.56,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tarka,00074328913,NDC,250,RC,,,,inpatient,1,EA,1.29,1.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PHOS-NaK,60258000601,NDC,250,RC,,,,inpatient,1,EA,0.48,0.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Viread,61958040101,NDC,250,RC,,,,inpatient,300,ML,28.43,24.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
A.E.R,50289325001,NDC,250,RC,,,,inpatient,1,UN  ,1.23,1.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Thrombin-JMI,60793021720,NDC,250,RC,,,,inpatient,20000,UN  ,172.94,147,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tab-A-Vite,00904053061,NDC,250,RC,,,,inpatient,1,EA,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Preparation H,00573287193A,NDC,250,RC,,,,inpatient,1,EA,0.21,0.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Minerin Creme,80681015500A,NDC,250,RC,,,,inpatient,1,EA,3.57,3.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
"NEEDLE INJECTR,LUER LOCK,CLOSD 1 EA",0269935433031000082,CDM,250,RC,,,,inpatient,1,EA,5.07,4.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pfizerpen,00049053028,NDC,250,RC,,,,inpatient,20000000,UN  ,34.12,29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levophed,00409337504G,NDC,250,RC,,,,inpatient,4000,GM,10,8.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zinc Oxide,00536131698A,NDC,250,RC,,,,inpatient,454,GM,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
"GELATIN, ABSORBABLE DENTAL PK EACH",0260482700009039601,CDM,250,RC,,,,inpatient,1,EA,1.48,1.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Benzoyl Peroxide Aqueous,54868205700A,NDC,250,RC,,,,inpatient,1,EA,2.07,1.76,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin B Complex with Vitamin C,80681012600A,NDC,250,RC,,,,inpatient,1,EA,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
SSD,43598021055A,NDC,250,RC,,,,inpatient,1,EA,12.12,10.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Complera,61958110101,NDC,250,RC,,,,inpatient,1,EA,84.8,72.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
EPINEPHrine,54288010310,NDC,250,RC,,,,inpatient,4,ML,15,12.75,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
MoviPrep,65649020175,NDC,250,RC,,,,inpatient,1,EA,26.72,22.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
AUTOMIX 3+3/AS COMPOUNDER SET 1 EAC,0269999950085412660,CDM,250,RC,,,,inpatient,1,EA,29.22,24.84,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Canasa,58914050156,NDC,250,RC,,,,inpatient,1000,ML,11.06,9.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sensi-Care Protective Barrier,00003325614A,NDC,250,RC,,,,inpatient,1,EA,7.24,6.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
LIP BALM (CHAPSTICK),0260610912333902301,CDM,250,RC,,,,inpatient,1,EA,27.3,23.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tarka,00074328713,NDC,250,RC,,,,inpatient,1,EA,1.29,1.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Betamethasone Sodium Phosphate-Betamethasone Ace,00517072001A,NDC,250,RC,,,,inpatient,15,ML,23.37,19.86,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
LACTOBACILLUS ACIDOPHILUS 1 TABLET,0269905574312051520A,CDM,250,RC,,,,inpatient,1,EA,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Recothrom,43825070750,NDC,250,RC,,,,inpatient,20000,UN  ,248.48,211.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bio Glo,17238090011A,NDC,250,RC,,,,inpatient,1,EA,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dianeal Low Calcium Peritoneal Dialysis w/Dextrose,00941043053,NDC,250,RC,,,,inpatient,2500,ML,33.33,28.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Thrombin-JMI,60793020505,NDC,250,RC,,,,inpatient,5000,UN  ,44.2,37.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
AMOX TR/POTASSIUM CLAVULANATE 125 M,0260413871297024035A,CDM,250,RC,,,,inpatient,125,ML,0.78,0.66,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nystatin,00472016615A,NDC,250,RC,,,,inpatient,1,EA,11.9,10.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Americaine,63736003751A,NDC,250,RC,,,,inpatient,1,EA,4.14,3.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Centrum Liquid,00005434462A,NDC,250,RC,,,,inpatient,15,ML,0.2,0.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Chloraseptic,78112001106,NDC,250,RC,,,,inpatient,1,EA,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydrophor,54162050001,NDC,250,RC,,,,inpatient,1,EA,8.46,7.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Renvela,58468013101,NDC,250,RC,,,,inpatient,2.4,GM,6.7,5.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
MiraLAX,11523723402,NDC,250,RC,,,,inpatient,119,GM,4.8,4.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Carbidopa-Levodopa,68084009401A,NDC,250,RC,,,,inpatient,1,EA,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Creon,00032120601A,NDC,250,RC,,,,inpatient,40,ML,10,8.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gelfoam,00009031508,NDC,250,RC,,,,inpatient,1,EA,4.01,3.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amoxicillin/Clavulanate Potassium,00781613957A,NDC,250,RC,,,,inpatient,600,ML,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aquaphor Healing Ointment,72140011047,NDC,250,RC,,,,inpatient,1,EA,1.97,1.67,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sulfamethoxazole/Trimethoprim,65862049647A,NDC,250,RC,,,,inpatient,40,ML,0.37,0.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Athlete's Foot,45802043401,NDC,250,RC,,,,inpatient,1,EA,2.97,2.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lactated Ringer's,00264775010,NDC,250,RC,,,,inpatient,500,ML,1.18,1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clinolipid,00338954006,NDC,250,RC,,,,inpatient,250,ML,49.39,41.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BUPivacaine HCl,00409116501C,NDC,636,RC,J3490,HCPCS,,outpatient,30,ML,25.46,21.64,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Ipol,49281086010B,NDC,250,RC,,,,inpatient,0.5,ML,26.87,22.84,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PERMETHRIN (NIX CREAM SCALP RINSE),0270079463736002403,CDM,250,RC,,,,inpatient,1,EA,9.07,7.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
clotrimazole-betamethasone dipropionate,00168025815,NDC,250,RC,,,,inpatient,1,EA,4.35,3.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dehydrated Alcohol,13925017710,NDC,250,RC,,,,inpatient,5,ML,84.05,71.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Advair Diskus 100/50,00173069504A,NDC,250,RC,,,,inpatient,1,EA,132.41,112.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Butorphanol Tartrate,00409162601,NDC,250,RC,,,,inpatient,2,ML,4.4,3.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tolnaftate,00536131543A,NDC,250,RC,,,,inpatient,1,EA,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
LMD w/0.9% Sodium Chloride,00409741903,NDC,250,RC,,,,inpatient,500,ML,20.7,17.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nystatin,51672128901C,NDC,250,RC,,,,inpatient,1,EA,37.05,31.49,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Symbicort 160/4.5,00186037028A,NDC,250,RC,,,,inpatient,1,EA,63.2,53.72,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amoxicillin/Clavulanate Potassium,00781183101,NDC,250,RC,,,,inpatient,1,EA,0.35,0.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calcium Gluconate,63323036019A,NDC,250,RC,,,,inpatient,1000,ML,8.58,7.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cloNIDine,51862045404A,NDC,250,RC,,,,inpatient,0.2,ML,10.14,8.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin D,00904582360,NDC,250,RC,,,,inpatient,400,UN  ,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lemon-Lime Flavor PEG-3350,10572030201B,NDC,250,RC,,,,inpatient,4000,ML,10.93,9.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sulfamethoxazole/Trimethoprim,70069036210A,NDC,250,RC,,,,inpatient,16,ML,6.48,5.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Trizivir,49702021718,NDC,250,RC,,,,inpatient,1,EA,6.67,5.67,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Symtuza,59676080030,NDC,250,RC,,,,inpatient,1,EA,117.69,100.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dex4,38396059563A,NDC,250,RC,,,,inpatient,3,ML,2.17,1.84,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Triumeq,49702023113A,NDC,250,RC,,,,inpatient,1,EA,114.38,97.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bacitracin Zinc,51672207502A,NDC,250,RC,,,,inpatient,1,EA,10.54,8.96,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
"INFUSION ADAPTER, CLOSED SYSTM 1 EA",0269935333031000043,CDM,250,RC,,,,inpatient,1,EA,2.71,2.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ondansetron,68462015713A,NDC,636,RC,Q0162,HCPCS,,outpatient,4,ML,0.02,0.02,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Plasma-Lyte 148,00338017904,NDC,250,RC,,,,inpatient,1000,ML,2.34,1.99,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Creon,00032263601,NDC,250,RC,,,,inpatient,1,UN  ,7.4,6.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexAMETHasone Intensol,00054317644C,NDC,250,RC,,,,inpatient,90,ML,28,23.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Surgilube,00281020545,NDC,250,RC,,,,inpatient,1,EA,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
"TRANSFER DEVICE, CLOSED SYSTEM 1 EA",0269935133031000006,CDM,250,RC,,,,inpatient,1,EA,4.56,3.88,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Depo-Provera Contraceptive,00009074630,NDC,250,RC,,,,inpatient,150,ML,23.35,19.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nystatin,42543005261A,NDC,250,RC,,,,inpatient,1,EA,3.04,2.58,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BUPivacaine HCl,00409116501A,NDC,250,RC,,,,inpatient,50,ML,31.46,26.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluocinonide,51672126403A,NDC,250,RC,,,,inpatient,1,EA,27.64,23.49,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lovenox,00075062040A,NDC,250,RC,,,,inpatient,40,ML,3.56,3.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Carbidopa/Levodopa/Entacapone,47335000588,NDC,250,RC,,,,inpatient,1,EA,2.93,2.49,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cycloPHOSphamide,00781324494A,NDC,636,RC,J9074,HCPCS,,outpatient,1000,ML,108.47,92.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.26,3783,,facility
SUCCINYLCHOLINE CHLORIDE 200 MG/10,0270073270092108746,CDM,250,RC,,,,inpatient,200,ML,28.25,24.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Good Neighbor Pharmacy Miconazorb AF,46122044427,NDC,250,RC,,,,inpatient,1,EA,4.38,3.72,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Breyna 160/4.5,00378750332,NDC,250,RC,,,,inpatient,1,EA,211.06,179.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
VITAMINS A AND D TOPICAL OINTMENT,0270001941100081122A,CDM,250,RC,,,,inpatient,1,EA,1.92,1.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Miochol-E,24208053920,NDC,250,RC,,,,inpatient,20,ML,59.1,50.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cloNIDine,51862045304A,NDC,250,RC,,,,inpatient,0.1,ML,6.32,5.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sore Throat Lozenges,00904625549,NDC,250,RC,,,,inpatient,1,EA,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levophed,00409337504D,NDC,250,RC,,,,inpatient,16000,GM,40,34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Recombivax HB Pediatric-Adolescent,00006498100,NDC,250,RC,,,,inpatient,5,GM,10.5,8.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Enfamil D-Vi-Sol,00087086644A,NDC,250,RC,,,,inpatient,400,UN  ,14.32,12.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
rivastigmine,00781730431A,NDC,250,RC,,,,inpatient,1,EA,3.97,3.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
SENNOSIDES/DOCUSATE COMBO (SENNA PL,0269963651645085099A,CDM,250,RC,,,,inpatient,1,EA,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Renvela,58468013201,NDC,250,RC,,,,inpatient,0.8,GM,16.93,14.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vasostrict,42023016425B,NDC,636,RC,J3490,HCPCS,,outpatient,40,UN  ,378.71,321.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Surgilube,00281020512,NDC,250,RC,,,,inpatient,56.7,GM,1.63,1.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cefoTEtan disodium,63323038510,NDC,250,RC,,,,inpatient,1,GM,8.29,7.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Antifungal,68001048145A,NDC,250,RC,,,,inpatient,1,EA,1.1,0.94,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluocinonide,00093026215A,NDC,250,RC,,,,inpatient,1,EA,7.52,6.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Delestrogen,42023011001,NDC,250,RC,,,,inpatient,10,ML,102.77,87.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clindamycin Phosphate,59762374301,NDC,250,RC,,,,inpatient,1,EA,31.84,27.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin D2,64380073706A,NDC,250,RC,,,,inpatient,50000,UN  ,1.14,0.97,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Antifungal,68001048148A,NDC,250,RC,,,,inpatient,1,EA,1.25,1.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tucks,30014010001A,NDC,250,RC,,,,inpatient,1,EA,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
GRX Analgesic Balm,54162055501,NDC,250,RC,,,,inpatient,1,EA,2.21,1.88,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
First Aid Antiseptic,00536127180A,NDC,250,RC,,,,inpatient,1,EA,1.2,1.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Alphagan P,00023932105,NDC,250,RC,,,,inpatient,1,EA,2.42,2.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ammonium Lactate,45802052555,NDC,250,RC,,,,inpatient,1,EA,3.58,3.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Actidose-Aqua,00574052174A,NDC,250,RC,,,,inpatient,25,GM,20.11,17.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
GELATIN SPONGE ABS SIZE 12-7 1 EACH,0270004463713001973,CDM,250,RC,,,,inpatient,1,EA,70.09,59.58,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clinolipid,00338954003,NDC,250,RC,,,,inpatient,500,ML,49.3,41.91,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluocinonide,00168013460A,NDC,250,RC,,,,inpatient,1,EA,60.1,51.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nephro-Vite Vitamin B and C Complex,00536730001,NDC,250,RC,,,,inpatient,1,EA,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cepastat,63736020418,NDC,250,RC,,,,inpatient,1,EA,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cholestyramine,42806026695A,NDC,250,RC,,,,inpatient,4,GM,1.37,1.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ketoconazole,51672129803,NDC,250,RC,,,,inpatient,1,EA,35.4,30.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Omeprazole,68462023130C,NDC,250,RC,,,,inpatient,2,ML,0.3,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cyanide Antidote,11098050701,NDC,250,RC,,,,inpatient,1,EA,339.13,288.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mupirocin,45802011222A,NDC,250,RC,,,,inpatient,1,EA,8.55,7.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Potassium Chloride,60687062871A,NDC,250,RC,,,,inpatient,20,UN  ,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Permethrin,00472024260A,NDC,250,RC,,,,inpatient,1,EA,45.38,38.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Smoflipid,63323082074A,NDC,250,RC,,,,inpatient,250,ML,24.66,20.96,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pfizerpen,00049052083,NDC,250,RC,,,,inpatient,5000000,UN  ,11.93,10.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aprodine,00904730224A,NDC,250,RC,,,,inpatient,1,EA,0.01,0.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amoxicillin/Clavulanate Potassium,00781187431,NDC,250,RC,,,,inpatient,1,EA,1.46,1.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Breyna 80/4.5,00378750232,NDC,250,RC,,,,inpatient,1,EA,193.3,164.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Omnipaque 350,00407141491,NDC,250,RC,,,,inpatient,100,ML,810.81,689.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nystop,00574200830,NDC,250,RC,,,,inpatient,1,EA,6.42,5.46,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Symbicort 80/4.5,00186037228,NDC,250,RC,,,,inpatient,1,EA,57.49,48.87,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bicillin L-A,60793070110,NDC,250,RC,,,,inpatient,1200000,UN  ,137.12,116.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pyrimethamine,38779088403A,NDC,250,RC,,,,inpatient,50,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
"Carbidopa, Levodopa and Entacapone",16571069401A,NDC,250,RC,,,,inpatient,1,EA,1.25,1.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cycloPHOSphamide,10019095501,NDC,636,RC,J9074,HCPCS,,outpatient,500,ML,132.79,112.87,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.26,3783,,facility
Odefsey,61958210101,NDC,250,RC,,,,inpatient,1,EA,117.15,99.58,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Senna-Lax,00904725261A,NDC,250,RC,,,,inpatient,1,EA,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clotrimazole,51672126003A,NDC,250,RC,,,,inpatient,1,EA,34.31,29.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Omidria,62225060000,NDC,636,RC,J1097,HCPCS,,outpatient,4,ML,472,401.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,101.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,125.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,494.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,125.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,101.29,3783,,facility
Infuvite Pediatric,54643564601,NDC,250,RC,,,,inpatient,5,ML,21.59,18.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nystatin/Triamcinolone Acetonide,51672127201B,NDC,250,RC,,,,inpatient,1,EA,78.64,66.84,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Eryped 200,24338013213A,NDC,250,RC,,,,inpatient,200,ML,1.8,1.53,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
"TRANSFER DEVICE, CLOSED SYSTEM 1 EA",0269935533031000009,CDM,250,RC,,,,inpatient,1,EA,5.94,5.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tubersol,49281075221,NDC,250,RC,,,,inpatient,5,UN  ,66.18,56.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tubersol,49281075221B,NDC,250,RC,,,,inpatient,5,UN  ,3.8,3.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ZINC OXIDE/PANTHENOL/VITAMIN E 56 G,0270001130103004500A,CDM,250,RC,,,,inpatient,1,EA,4.83,4.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Engerix-B,58160082111,NDC,250,RC,,,,inpatient,20,GM,50.61,43.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mucinex DM,63824005634,NDC,250,RC,,,,inpatient,1,EA,0.24,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Brimonidine Tartrate,70069023301A,NDC,250,RC,,,,inpatient,1,EA,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dianeal Low Calcium Peritoneal Dialysis w/Dextrose,00941043355A,NDC,250,RC,,,,inpatient,2500,ML,33.33,28.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Biktarvy,61958250101,NDC,250,RC,,,,inpatient,1,EA,128.73,109.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Butalbital-Acetaminophen-Caffeine,70010014901A,NDC,250,RC,,,,inpatient,1,EA,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
oxyCODONE HCl-acetaminophen,00406051262B,NDC,250,RC,,,,inpatient,1,EA,0.25,0.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Trelegy Ellipta,00173088714,NDC,250,RC,,,,inpatient,1,EA,135.03,114.78,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ketoconazole,51672129801,NDC,250,RC,,,,inpatient,1,EA,15.6,13.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cholestyramine Light,49884046665A,NDC,250,RC,,,,inpatient,4,GM,1.13,0.96,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zinc Oxide,75834017001A,NDC,250,RC,,,,inpatient,1,EA,0.17,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Metamucil MultiHealth Fiber Sugar-Free,37000002404A,NDC,250,RC,,,,inpatient,5.85,GM,0.63,0.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tobradex,00078087601,NDC,250,RC,,,,inpatient,1,EA,215.38,183.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Blephamide,11980002205,NDC,250,RC,,,,inpatient,1,EA,144.9,123.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ammonium Lactate,45802051377A,NDC,250,RC,,,,inpatient,1,EA,2.74,2.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Praxbind,00597019705,NDC,636,RC,J3590,HCPCS,,outpatient,2.5,GM,4279.26,3637.37,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Creon,00032301613,NDC,250,RC,,,,inpatient,1,UN  ,10.97,9.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Piperacillin Sodium-Tazobactam Sodium Novaplus,00781921095A,NDC,250,RC,,,,inpatient,2.25,GM,1.74,1.48,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hemabate,00009085608,NDC,250,RC,,,,inpatient,250,GM,335.01,284.76,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Trelegy Ellipta,00173089314,NDC,250,RC,,,,inpatient,1,EA,89.11,75.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
miSOPROStol,60687074601A,NDC,250,RC,,,,inpatient,200,GM,0.77,0.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pramosone,54766072906,NDC,250,RC,,,,inpatient,1,EA,0.74,0.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Multitrace-5 Concentrate,00517820125,NDC,250,RC,,,,inpatient,1,ML,7.35,6.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zostavax,00006496341,NDC,250,RC,,,,inpatient,19400,UN  ,184.14,156.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cleocin T,00009311601A,NDC,250,RC,,,,inpatient,1,EA,6.67,5.67,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin D3 AvPak,50268086615,NDC,250,RC,,,,inpatient,125,GM,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Carbidopa-Levodopa,68084028101A,NDC,250,RC,,,,inpatient,1,EA,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tarka,00074328813,NDC,250,RC,,,,inpatient,1,EA,1.29,1.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
GOWN CHEMO XLG 1 EACH EACH,0269994800000500201,CDM,250,RC,,,,inpatient,1,EA,2.81,2.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin D3,80681016900A,NDC,250,RC,,,,inpatient,1000,UN  ,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Medihoney,09958003361,NDC,250,RC,,,,inpatient,1,EA,13.82,11.75,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
CetaKlenz,00904584416,NDC,250,RC,,,,inpatient,1,EA,2.49,2.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Potassium Chloride,68001056700A,NDC,250,RC,,,,inpatient,20,UN  ,0.42,0.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gelfoam,00009035301,NDC,250,RC,,,,inpatient,1,EA,17.94,15.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Creon,00032120601,NDC,250,RC,,,,inpatient,1,UN  ,1.27,1.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lovenox,00075062430A,NDC,250,RC,,,,inpatient,30,ML,2.32,1.97,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sucralfate,51079075320A,NDC,250,RC,,,,inpatient,1,GM,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bicillin L-A,60793070210,NDC,250,RC,,,,inpatient,2400000,UN  ,305.9,260.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Kaletra,00074679922,NDC,250,RC,,,,inpatient,1,EA,6.63,5.64,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Minerin Creme,00904775127A,NDC,250,RC,,,,inpatient,1,EA,3.51,2.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Relistor,65649015090,NDC,360,RC,52282,CPT,,outpatient,150,ML,24.37,20.71,1648,,,,,,,fee schedule,,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4091,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4060,,,,,,,fee schedule,,4060,,,,,,,fee schedule,,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4159.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4597.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18171.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,15412.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4597.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6310,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6310,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,18171.27,,facility
Recothrom,43825060641,NDC,250,RC,,,,inpatient,5000,UN  ,81.64,69.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
MULTIVITAMINS THER W-MINERALS COMBO,0260526311917009502A,CDM,250,RC,,,,inpatient,1,EA,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Carbidopa-Levodopa,00378009401A,NDC,250,RC,,,,inpatient,1,EA,0.55,0.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluticasone Propionate,00054327099A,NDC,250,RC,,,,inpatient,60,EA,6.68,5.68,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ergocalciferol,69367028302A,NDC,250,RC,,,,inpatient,8000,UN  ,2.55,2.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Quelicin,00409662902,NDC,250,RC,,,,inpatient,200,ML,0.75,0.64,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Anoro Ellipta,00173086906,NDC,250,RC,,,,inpatient,1,EA,61.17,51.99,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
MICROFIBRILLAR COLLAGEN 1 GM EACH,0260929600998101002,CDM,250,RC,,,,inpatient,1,GM,107.38,91.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
clotrimazole-betamethasone dipropionate,00168025846A,NDC,250,RC,,,,inpatient,1,EA,11.71,9.95,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lovenox,00075062160A,NDC,250,RC,,,,inpatient,60,ML,4.58,3.89,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Carbidopa-Levodopa,50228045810A,NDC,250,RC,,,,inpatient,1,EA,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydroxyurea,68084028401A,NDC,636,RC,J8999,HCPCS,,outpatient,500,ML,0.67,0.57,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
Stiolto Respimat,00597015561A,NDC,636,RC,J3535,HCPCS,,outpatient,1,EA,16.61,14.12,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
Botox,00023114501,NDC,636,RC,J0585,HCPCS,,outpatient,100,UN  ,634,538.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.19,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.19,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.53,3783,,facility
Combivent Respimat,00597002402,NDC,636,RC,J3535,HCPCS,,outpatient,1,EA,363.13,308.66,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
cycloPHOSphamide,10019098201A,NDC,636,RC,J8530,HCPCS,,outpatient,25,ML,0.97,0.82,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Privigen,44206043940,NDC,636,RC,J1459,HCPCS,,outpatient,400,ML,4266.8,3626.78,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,208.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,52.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45.01,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45.01,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.74,3783,,facility
Megestrol Acetate,00555060702B,NDC,636,RC,J8999,HCPCS,,outpatient,40,ML,0.22,0.19,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
Procrit,59676031002,NDC,636,RC,J0885,HCPCS,,outpatient,10000,UN  ,136.87,116.34,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.22,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.22,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.58,3783,,facility
Leukeran,80725061025A,NDC,636,RC,J8999,HCPCS,,outpatient,2,ML,3.3,2.81,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
HyperTET,13533063402,NDC,636,RC,J1670,HCPCS,,outpatient,250,UN  ,466.95,396.91,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,500.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,617.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2442.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,617.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,482.08,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,466.95,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,588.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,466.95,3783,,facility
Gamunex-C,13533080024,NDC,636,RC,J1561,HCPCS,,outpatient,20,GM,1356.38,1152.92,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,41.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,203.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,51.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41.72,3783,,facility
Megestrol Acetate,00555060602A,NDC,250,RC,J8999,HCPCS,,inpatient,20,ML,0.4,0.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aranesp,55513002104,NDC,636,RC,J0881,HCPCS,,outpatient,40,GM,80.66,68.56,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.09,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.09,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.57,3783,,facility
Privigen,44206043820,NDC,636,RC,J1459,HCPCS,,outpatient,200,ML,1406.93,1195.89,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,208.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,52.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45.01,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45.01,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.74,3783,,facility
Orencia,00003218713A,NDC,636,RC,J0129,HCPCS,,outpatient,250,ML,530.08,450.57,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,38.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,47.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44.52,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44.52,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,38.05,3783,,facility
Gammaked,76125090010,NDC,636,RC,J1561,HCPCS,,outpatient,10,GM,838.1,712.39,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,41.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,203.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,51.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41.72,3783,,facility
Flebogamma 10% DIF,61953000503,NDC,636,RC,J1572,HCPCS,,outpatient,200,ML,994.68,845.48,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,77.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,95.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,376.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,95.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.89,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35.89,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,90.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.89,3783,,facility
Carnitor,54482014701,NDC,636,RC,J1955,HCPCS,,outpatient,1000,ML,31.42,26.71,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
Gamunex-C,13533080020A,NDC,636,RC,J1561,HCPCS,,outpatient,5,GM,462.73,393.32,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,41.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,203.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,51.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41.72,3783,,facility
Fuzeon,00004038039,NDC,636,RC,J1324,HCPCS,,outpatient,90,ML,42.8,36.38,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
Methotrexate Sodium,51079067005A,NDC,636,RC,J8610,HCPCS,,outpatient,2.5,ML,1.23,1.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Cellcept,00004025901,NDC,636,RC,J7517,HCPCS,,outpatient,250,ML,0.17,0.14,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Gammagard Liquid,00944270004,NDC,636,RC,J1569,HCPCS,,outpatient,5,GM,248.18,210.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,40.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,49.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,196.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40.2,3783,,facility
Tretinoin,68084007521,NDC,636,RC,J8999,HCPCS,,outpatient,10,ML,22,18.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
Botox,00023392102,NDC,636,RC,J0585,HCPCS,,outpatient,200,UN  ,951.23,808.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.19,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.19,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.53,3783,,facility
Venclexta,00074056607,NDC,636,RC,J8999,HCPCS,,outpatient,50,ML,48.78,41.46,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
Mycophenolate Mofetil,67877023022A,NDC,636,RC,J7517,HCPCS,,outpatient,200,ML,6.2,5.27,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SandIMMUNE,00078024115,NDC,636,RC,J7502,HCPCS,,outpatient,100,ML,13.38,11.37,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Gamunex-C,13533080040,NDC,636,RC,J1561,HCPCS,,outpatient,40,GM,2409.94,2048.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,41.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,203.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,51.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41.72,3783,,facility
Menactra,49281058905,NDC,636,RC,90733,CPT,,outpatient,4,GM,110.45,93.88,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
Privigen,44206043605,NDC,636,RC,J1459,HCPCS,,outpatient,50,ML,357.5,303.88,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,208.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,52.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45.01,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45.01,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.74,3783,,facility
Depocyt,57665033101,NDC,636,RC,J9098,HCPCS,,outpatient,50,ML,2413.19,2051.21,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,3783,,facility
Privigen,44206043710,NDC,636,RC,J1459,HCPCS,,outpatient,100,ML,715,607.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,208.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,52.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45.01,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45.01,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.74,3783,,facility
Gamunex-C,13533080071A,NDC,636,RC,J1561,HCPCS,,outpatient,10,GM,692.39,588.53,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,41.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,203.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,51.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41.72,3783,,facility
Gammaked,76125090020,NDC,636,RC,J1561,HCPCS,,outpatient,20,GM,1619.63,1376.69,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,41.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,203.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,51.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41.72,3783,,facility
Gammagard Liquid,00944270007,NDC,636,RC,J1569,HCPCS,,outpatient,30,GM,2622,2228.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,40.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,49.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,196.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40.2,3783,,facility
Aranesp,55513005704,NDC,636,RC,J0881,HCPCS,,outpatient,25,GM,46.3,39.36,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.09,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.09,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.57,3783,,facility
Mycophenolate Mofetil,60687043801A,NDC,636,RC,J7517,HCPCS,,outpatient,500,ML,9.07,7.71,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Testosterone,21922001902A,NDC,250,RC,,,,inpatient,5,GM,9.14,7.77,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Adrenalin,42023015925,NDC,250,RC,,,,inpatient,1,ML,13.28,11.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
HYDROmorphone *PCA* 10MG/50ML DISP.,0270073870092111450,CDM,250,RC,,,,inpatient,10,ML,0.79,0.67,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Emtriva,61958060101,NDC,250,RC,,,,inpatient,200,ML,15.58,13.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ARIPiprazole,31722082930A,NDC,250,RC,,,,inpatient,20,ML,1.59,1.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ibuprofen,00904674770A,NDC,250,RC,,,,inpatient,200,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
metOLazone,51079002320,NDC,250,RC,,,,inpatient,2.5,ML,2.38,2.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
metroNIDAZOLE,68001036400A,NDC,250,RC,,,,inpatient,250,ML,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methylergonovine Maleate,51991014417A,NDC,250,RC,,,,inpatient,0.2,ML,15.5,13.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cortef,00009001201,NDC,250,RC,,,,inpatient,5,ML,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Selenium Sulfide,42192015206,NDC,250,RC,,,,inpatient,1,EA,56.73,48.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
diazePAM,68682065520A,NDC,250,RC,,,,inpatient,20,ML,242.08,205.77,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xylocaine-MPF,63323049227A,NDC,250,RC,,,,inpatient,10,ML,0.51,0.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydroxychloroquine Sulfate,68084026901A,NDC,250,RC,,,,inpatient,200,ML,1.43,1.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Silver Nitrate,12870000101A,NDC,250,RC,,,,inpatient,1,EA,0.46,0.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,00409428301,NDC,250,RC,,,,inpatient,5,ML,2.42,2.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Demerol Hydrochloride,00409117830,NDC,250,RC,,,,inpatient,50,ML,5.12,4.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Angiomax,00781344795,NDC,250,RC,,,,inpatient,250,ML,676.08,574.67,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methadone HCl,00406575562A,NDC,250,RC,,,,inpatient,5,ML,0.29,0.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ARIPiprazole,62332009831A,NDC,250,RC,,,,inpatient,5,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetic Acid,00990614309,NDC,250,RC,,,,inpatient,1000,ML,3.7,3.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexAMETHasone,00054817625,NDC,250,RC,,,,inpatient,2,ML,0.54,0.46,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
DOBUTamine HCl,00409234402,NDC,250,RC,,,,inpatient,250000,GM,43.08,36.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mineral Oil,48433020230B,NDC,250,RC,,,,inpatient,25,ML,0.26,0.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
glyBURIDE Micronized,00093803401A,NDC,250,RC,,,,inpatient,1.5,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Proparacaine HCl,61314001601A,NDC,250,RC,,,,inpatient,1,EA,33.3,28.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dipyridamole,00115107001A,NDC,250,RC,,,,inpatient,25,ML,0.24,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
rOPINIRole HCl,68462025401A,NDC,250,RC,,,,inpatient,0.5,ML,1.64,1.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Duramorph,00641602010B,NDC,250,RC,,,,inpatient,1,ML,3,2.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calcionate,00536277085,NDC,250,RC,,,,inpatient,1.8,GM,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lupron Depot-Ped,00074210803B,NDC,250,RC,,,,inpatient,7.5,ML,104.34,88.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
diphenhydrAMINE HCl,00641037625,NDC,250,RC,,,,inpatient,50,ML,0.53,0.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ramipril,68001042800A,NDC,250,RC,,,,inpatient,1.25,ML,0.22,0.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00990798361A,NDC,250,RC,,,,inpatient,150,ML,0.71,0.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose-Sodium Chloride,00338008504,NDC,250,RC,,,,inpatient,1000,ML,1.92,1.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Emverm,64896066930A,NDC,250,RC,,,,inpatient,100,ML,3.03,2.58,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Doxepin HCl,51079043820,NDC,250,RC,,,,inpatient,50,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lanoxin Pediatric,70515026210,NDC,250,RC,,,,inpatient,0.1,ML,53.46,45.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
HYDROmorphone HCl,42858030125A,NDC,250,RC,,,,inpatient,2,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ARIPiprazole,16729027801A,NDC,250,RC,,,,inpatient,2,ML,25.28,21.49,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Piperacillin and Tazobactam,64679005601A,NDC,250,RC,,,,inpatient,3.375,GM,5.26,4.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prograf,00469060773,NDC,250,RC,,,,inpatient,0.5,ML,1.94,1.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
methazolAMIDE,62559024001A,NDC,250,RC,,,,inpatient,25,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
FLUoxetine HCl,00904578461A,NDC,250,RC,,,,inpatient,10,ML,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Abilify,59148001113A,NDC,250,RC,,,,inpatient,30,ML,23.14,19.67,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nystatin,00121086800A,NDC,250,RC,,,,inpatient,120,ML,17.95,15.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Latanoprost,61314054701A,NDC,250,RC,,,,inpatient,1,EA,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Montelukast Sodium,68084087501A,NDC,250,RC,,,,inpatient,10,ML,0.21,0.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Albumin Human,68982064302A,NDC,250,RC,,,,inpatient,25,GM,6.4,5.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Temozolomide,16729005054A,NDC,250,RC,,,,inpatient,100,ML,181.69,154.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluorouracil,68001052431,NDC,250,RC,,,,inpatient,1000,ML,10.04,8.53,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
guaiFENesin,00121174405,NDC,250,RC,,,,inpatient,100,ML,0.53,0.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl,63323028420B,NDC,250,RC,,,,inpatient,1000,ML,5.5,4.68,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Demerol Hydrochloride,00409117630A,NDC,250,RC,,,,inpatient,25,ML,4.96,4.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
NOREPINEPHRINE-NS 8 MG/250 ML (PRE-,0270106970092103505,CDM,250,RC,,,,inpatient,8,ML,28.69,24.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gemfibrozil,60687022401A,NDC,250,RC,,,,inpatient,600,ML,0.25,0.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Piperacillin and Tazobactam,44567080110A,NDC,250,RC,,,,inpatient,2.25,GM,4.83,4.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PHENobarbital Sodium,00641047725,NDC,250,RC,,,,inpatient,130,ML,34.36,29.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Divalproex Sodium,68084041501A,NDC,250,RC,,,,inpatient,500,ML,4.28,3.64,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
quiNIDine Gluconate,00002140701,NDC,250,RC,,,,inpatient,800,ML,17.56,14.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Furosemide,36000028325A,NDC,250,RC,,,,inpatient,40,ML,1.07,0.91,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitrase,24208000202A,NDC,250,RC,,,,inpatient,200,UN  ,41.77,35.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ciprofloxacin in Dextrose,25021011482A,NDC,250,RC,,,,inpatient,200,ML,1.66,1.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nimbex,00074438220,NDC,250,RC,,,,inpatient,200,ML,135.72,115.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Polocaine-MPF,63323029427A,NDC,250,RC,,,,inpatient,20,ML,2.79,2.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00338001718A,NDC,250,RC,,,,inpatient,100,ML,2.38,2.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ferrous Sulfate,00121053005,NDC,250,RC,,,,inpatient,300,ML,0.35,0.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
carBAMazepine,00904617261A,NDC,250,RC,,,,inpatient,200,ML,0.7,0.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
NIFEdipine,50742026101A,NDC,250,RC,,,,inpatient,60,ML,0.66,0.56,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00338002303,NDC,250,RC,,,,inpatient,500,ML,0.9,0.77,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
guaiFENesin DM,00121063800,NDC,250,RC,,,,inpatient,5,ML,1.59,1.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Meropenem,63323050830B,NDC,250,RC,,,,inpatient,1,GM,68.63,58.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
niCARdipine HCl,00517073510A,NDC,250,RC,,,,inpatient,25,ML,23,19.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Unasyn,00049002428,NDC,250,RC,,,,inpatient,15,GM,70.08,59.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mupirocin,68462056417A,NDC,250,RC,,,,inpatient,1,EA,129.91,110.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Piperacillin and Tazobactam,68001050831B,NDC,250,RC,,,,inpatient,4.5,GM,8.77,7.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
atropine-hyoscyamine-PHENobarbital-scopolamine,50742066604A,NDC,250,RC,,,,inpatient,5,ML,14.29,12.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Isoproterenol HCl,72485011310A,NDC,250,RC,,,,inpatient,0.2,ML,17.79,15.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clindamycin HCl,68084024301A,NDC,250,RC,,,,inpatient,150,ML,0.19,0.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cefOXitin Sodium,25021010910A,NDC,250,RC,,,,inpatient,1,GM,7.04,5.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,00409427602,NDC,250,RC,,,,inpatient,50,ML,1.34,1.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nitro-Dur,50742051530A,NDC,250,RC,,,,inpatient,0.3,ML,4.2,3.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pantoprazole Sodium,68084064301A,NDC,250,RC,,,,inpatient,20,ML,0.2,0.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Temozolomide,16729005153A,NDC,250,RC,,,,inpatient,250,ML,454.35,386.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Divalproex Sodium,68084078261A,NDC,250,RC,,,,inpatient,500,ML,0.17,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morrhuate Sodium,00517306501,NDC,250,RC,,,,inpatient,50,ML,58.61,49.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Furosemide,68094086762A,NDC,250,RC,,,,inpatient,40,ML,1.67,1.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Chantix,00069046956,NDC,250,RC,,,,inpatient,1,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Januvia,00006011228A,NDC,250,RC,,,,inpatient,50,ML,14.13,12.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00264751010,NDC,250,RC,,,,inpatient,500,ML,0.72,0.61,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zemplar,00074165805A,NDC,250,RC,,,,inpatient,10,GM,21.98,18.68,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Imipenem and Cilastatin,63323034925A,NDC,250,RC,,,,inpatient,250,ML,7.8,6.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fondaparinux Sodium,67457058304A,NDC,250,RC,,,,inpatient,5,ML,5.25,4.46,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prasugrel,16729027210A,NDC,250,RC,,,,inpatient,5,ML,14.81,12.59,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Octreotide Acetate,63323037701A,NDC,250,RC,,,,inpatient,500,GM,9.66,8.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mannitol,00409403101A,NDC,250,RC,,,,inpatient,12.5,GM,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00641612525,NDC,250,RC,,,,inpatient,4,ML,2.08,1.77,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Protonix IV,00008092360B,NDC,250,RC,,,,inpatient,40,ML,8.93,7.59,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amitriptyline HCl,51079014720,NDC,250,RC,,,,inpatient,75,ML,0.59,0.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Albuterol Sulfate,70710106101A,NDC,250,RC,,,,inpatient,2,ML,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Noritate,00187520260,NDC,250,RC,,,,inpatient,60,GM,133.49,113.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prograf,00469061773,NDC,250,RC,,,,inpatient,1,ML,0.65,0.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
LORazepam,00641604425A,NDC,250,RC,,,,inpatient,2,ML,4.45,3.78,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Strattera,00002322830,NDC,250,RC,,,,inpatient,25,ML,5.59,4.75,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Medrol,00009002001,NDC,250,RC,,,,inpatient,2,ML,1.54,1.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Valproic Acid,62559026616A,NDC,250,RC,,,,inpatient,250,ML,0.01,0.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Metoprolol Tartrate,62584026501A,NDC,250,RC,,,,inpatient,25,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cervidil,55566280001,NDC,250,RC,,,,inpatient,10,ML,481.41,409.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bumetanide,00641600810A,NDC,250,RC,,,,inpatient,0.25,ML,0.3,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
glyBURIDE Micronized,00093803501B,NDC,250,RC,,,,inpatient,3,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Azilect,68546022956,NDC,250,RC,,,,inpatient,1,ML,17.01,14.46,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zyvox,00009514004A,NDC,250,RC,,,,inpatient,600,ML,7.54,6.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pilocarpine HCl,61314020615,NDC,250,RC,,,,inpatient,1,EA,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00409710002,NDC,250,RC,,,,inpatient,1,EA,1.59,1.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Codeine Phosphate/guaiFENesin,00121177540A,NDC,250,RC,,,,inpatient,5,ML,9.23,7.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
QUEtiapine Fumarate,71093013502A,NDC,250,RC,,,,inpatient,50,ML,6.84,5.81,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
EPINEPHrine,00409493301A,NDC,250,RC,,,,inpatient,1,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
fentaNYL Citrate,00409909431A,NDC,250,RC,,,,inpatient,1000,GM,1.91,1.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
diazePAM,68682065220A,NDC,250,RC,,,,inpatient,10,ML,273.29,232.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Famotidine,68180015001,NDC,250,RC,,,,inpatient,40,ML,2.69,2.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00338071906,NDC,250,RC,,,,inpatient,2000,ML,9.17,7.79,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
hydrALAZINE HCl,62584073301A,NDC,250,RC,,,,inpatient,25,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Comvax,00006489800,NDC,250,RC,,,,inpatient,0.5,ML,38.4,32.64,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Leucovorin Calcium,00703514501,NDC,250,RC,,,,inpatient,350,ML,11.8,10.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00338004903,NDC,250,RC,,,,inpatient,500,ML,0.74,0.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ampicillin,65219001810A,NDC,250,RC,,,,inpatient,1,GM,2.23,1.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Isoniazid,51079008320,NDC,250,RC,,,,inpatient,300,ML,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
imatinib mesylate,43598034530A,NDC,250,RC,,,,inpatient,400,ML,172.44,146.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
AK-Fluor,17478025310,NDC,250,RC,,,,inpatient,500,ML,18.89,16.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl,00409433201,NDC,250,RC,,,,inpatient,500,ML,7.52,6.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clarithromycin,68084065125A,NDC,250,RC,,,,inpatient,500,ML,3.82,3.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
risperiDONE,68084027401,NDC,250,RC,,,,inpatient,3,ML,0.48,0.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pioglitazone HCl,00093727156A,NDC,250,RC,,,,inpatient,15,ML,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nortriptyline HCl,00093081001A,NDC,250,RC,,,,inpatient,10,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
nebivolol hydrochloride,43547052509A,NDC,250,RC,,,,inpatient,5,ML,5.09,4.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gabapentin,65162010110A,NDC,250,RC,,,,inpatient,100,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Adacel,49281040010,NDC,250,RC,,,,inpatient,0.5,ML,30.59,26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
hydroCHLOROthiazide,16729018301A,NDC,250,RC,,,,inpatient,25,ML,0.16,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tetracaine HCl,00065074114a,NDC,250,RC,,,,inpatient,1,EA,2.87,2.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Azactam,00003257016B,NDC,250,RC,,,,inpatient,2,GM,65.4,55.59,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Betamethasone Dipropionate,00168005515,NDC,250,RC,,,,inpatient,1,EA,27.2,23.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Triamcinolone Acetonide,45802006535A,NDC,250,RC,,,,inpatient,1,EA,2.03,1.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
levOCARNitine,64980050312A,NDC,250,RC,,,,inpatient,500,ML,0.27,0.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Bicarbonate,63323008950A,NDC,250,RC,,,,inpatient,50,UN  ,0.17,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Promethazine HCl,00641092825,NDC,250,RC,,,,inpatient,25,ML,0.84,0.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
methIMAzole,49884064001A,NDC,250,RC,,,,inpatient,5,ML,0.27,0.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,00409427601,NDC,250,RC,,,,inpatient,10,ML,1.09,0.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Potassium Chl-Dextrose-Sodium Chl,00338067104,NDC,250,RC,,,,inpatient,20,UN  ,1.21,1.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pramipexole Dihydrochloride,13668009290A,NDC,250,RC,,,,inpatient,0.25,ML,0.19,0.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Twinrix,58160081552,NDC,250,RC,,,,inpatient,1,ML,89.52,76.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
glipiZIDE,51079081120,NDC,250,RC,,,,inpatient,10,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mycophenolic Acid,68084091825,NDC,250,RC,,,,inpatient,360,ML,6.56,5.58,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nimbex,00074437805,NDC,250,RC,,,,inpatient,10,ML,12.91,10.97,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Indocyanine Green,70100042402A,NDC,250,RC,,,,inpatient,25,ML,149.55,127.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Losartan Potassium,68084034701B,NDC,250,RC,,,,inpatient,50,ML,0.24,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Phenylephrine HCl,70756062925A,NDC,250,RC,,,,inpatient,1,EA,85.32,72.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Doxepin HCl,51079043620,NDC,250,RC,,,,inpatient,10,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lactulose,00121115440A,NDC,250,RC,,,,inpatient,20,GM,3.56,3.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
MAGNESIUM SULFATE 16 OZ CRYSTALS,0269843711822372340A,CDM,250,RC,,,,inpatient,1,EA,1.15,0.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
IV PIGGYBACK ADMINSTRATION SET 1 EA,0269934533031000100,CDM,250,RC,,,,inpatient,1,EA,3.94,3.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Promethazine HCl,70408014634A,NDC,250,RC,,,,inpatient,6.25,ML,0.01,0.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Meclizine HCl,60687073001A,NDC,250,RC,,,,inpatient,25,ML,0.39,0.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
busPIRone HCl,00378116580,NDC,250,RC,,,,inpatient,15,ML,0.24,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Temozolomide,67877054007A,NDC,250,RC,,,,inpatient,140,ML,254.36,216.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Polocaine-MPF,63323029337A,NDC,250,RC,,,,inpatient,15,ML,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gentamicin Sulfate,45802004635A,NDC,250,RC,,,,inpatient,1,EA,33.71,28.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ceFAZolin Sodium-Dextrose,00264310511,NDC,250,RC,,,,inpatient,2,GM,7.11,6.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pilocarpine HCl,70069018101A,NDC,250,RC,,,,inpatient,1,EA,70.37,59.81,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Jardiance,00597015237,NDC,250,RC,,,,inpatient,10,ML,12.67,10.77,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Potassium Chloride in Sodium Chloride,00338069104,NDC,250,RC,,,,inpatient,20,UN  ,1.21,1.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acyclovir AvPak,50268006115A,NDC,250,RC,,,,inpatient,400,ML,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bumetanide,00185012801A,NDC,250,RC,,,,inpatient,0.5,ML,0.4,0.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ofloxacin,24208041005,NDC,250,RC,,,,inpatient,1,EA,3.27,2.78,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dilantin-125,00071221435,NDC,250,RC,,,,inpatient,125,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,76329301305,NDC,250,RC,,,,inpatient,10,ML,6.23,5.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ofloxacin,60505056000A,NDC,250,RC,,,,inpatient,1,EA,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Perphenazine,00603506021,NDC,250,RC,,,,inpatient,2,ML,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Belbuca,59385002160,NDC,250,RC,,,,inpatient,75,GM,5.67,4.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
busPIRone HCl,29300024401A,NDC,250,RC,,,,inpatient,5,ML,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Depakote,00074732513,NDC,250,RC,,,,inpatient,125,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lubrifresh P.M.,00904648838A,NDC,250,RC,,,,inpatient,1,EA,11.94,10.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Eliquis,00003089331A,NDC,250,RC,,,,inpatient,2.5,ML,6.27,5.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Synthroid,00074706911,NDC,250,RC,,,,inpatient,150,GM,0.59,0.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mouthkote,50930009808,NDC,250,RC,,,,inpatient,1,EA,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Furosemide,00409163910A,NDC,250,RC,,,,inpatient,10,ML,2.34,1.99,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Etomidate,72266014710A,NDC,250,RC,,,,inpatient,40,ML,2.32,1.97,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calcitriol,00054312041A,NDC,250,RC,,,,inpatient,1,GM,5.36,4.56,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Granisetron Hydrochloride,51991073532A,NDC,250,RC,,,,inpatient,1,ML,2.45,2.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
acetaZOLAMIDE,39822019001,NDC,250,RC,,,,inpatient,500,ML,18.18,15.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BUPivacaine HCl,00409116001,NDC,250,RC,,,,inpatient,125,ML,0.61,0.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Octreotide Acetate,25021045101A,NDC,250,RC,,,,inpatient,50,GM,1.97,1.67,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Triamcinolone Acetonide,45802004501A,NDC,250,RC,,,,inpatient,1,EA,85.77,72.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
TDVAX,13533013101,NDC,250,RC,,,,inpatient,0.5,ML,20.73,17.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sotalol HCl,68084065401A,NDC,250,RC,,,,inpatient,80,ML,0.9,0.77,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
chlorproMAZINE HCl,00641139735A,NDC,250,RC,,,,inpatient,25,ML,5.41,4.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Onfi,67386031401,NDC,250,RC,,,,inpatient,10,ML,0.63,0.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Banophen,00904723761A,NDC,250,RC,,,,inpatient,25,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetaminophen,00904672080A,NDC,250,RC,,,,inpatient,500,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexAMETHasone,00054817925A,NDC,250,RC,,,,inpatient,0.5,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vasostrict,42023016425A,NDC,250,RC,,,,inpatient,20,UN  ,11.65,9.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nabi-HB,69800420301,NDC,250,RC,,,,inpatient,5,ML,96.72,82.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Belbuca,59385002260,NDC,250,RC,,,,inpatient,150,GM,5.67,4.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Coreg CR,80725038313,NDC,250,RC,,,,inpatient,10,ML,3.92,3.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Escitalopram,51079054420A,NDC,250,RC,,,,inpatient,20,ML,0.16,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calcitonin-Salmon,60505082306,NDC,250,RC,,,,inpatient,1,EA,33.71,28.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
DOXOrubicin HCl,63323088330,NDC,250,RC,,,,inpatient,50,ML,7.96,6.77,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Docusate Sodium,00121187000A,NDC,250,RC,,,,inpatient,100,ML,1.61,1.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amiodarone HCl,63323061603,NDC,250,RC,,,,inpatient,150,ML,1.07,0.91,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cefpodoxime Proxetil,65862009620A,NDC,250,RC,,,,inpatient,200,ML,7.87,6.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dilantin,00071374066B,NDC,250,RC,,,,inpatient,30,ML,0.4,0.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
sulfaSALAzine,00093323410,NDC,250,RC,,,,inpatient,500,ML,0.01,0.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mirtazapine,51079008720,NDC,250,RC,,,,inpatient,30,ML,0.19,0.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Delestrogen,42023011101,NDC,250,RC,,,,inpatient,20,ML,35.49,30.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Water For Injection,00338001304,NDC,250,RC,,,,inpatient,1000,ML,4.72,4.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00338055111A,NDC,250,RC,,,,inpatient,50,ML,3.22,2.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
MANNITOL 20% IV PREMIX BAG (200 MG/,0270108900990771512,CDM,250,RC,,,,inpatient,200,ML,18.82,16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
droNABinol,42858086806A,NDC,250,RC,,,,inpatient,5,ML,3.93,3.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Solu-CORTEF 100mg Vial,00009001104A,NDC,250,RC,,,,inpatient,100,ML,19.03,16.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
mitoMYcin,55390025201A,NDC,250,RC,,,,inpatient,1,EA,72.22,61.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Esmolol HCl,63323065210,NDC,250,RC,,,,inpatient,100000,GM,2.83,2.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Polocaine-MPF,63323026037A,NDC,250,RC,,,,inpatient,30,ML,5.07,4.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cytomel,60793011601,NDC,250,RC,,,,inpatient,25,GM,1.03,0.88,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Omnipaque 180,00407141110,NDC,250,RC,,,,inpatient,1,ML,13.37,11.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
niMODipine,23155051230,NDC,250,RC,,,,inpatient,30,ML,2.64,2.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Haloperidol,51079073520,NDC,250,RC,,,,inpatient,2,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Promethegan,00713053612A,NDC,250,RC,,,,inpatient,12.5,ML,7.89,6.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vecuronium Bromide,55150023620A,NDC,250,RC,,,,inpatient,20,ML,125.11,106.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
CISplatin,00703574711,NDC,250,RC,,,,inpatient,50,ML,8.27,7.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calcium Chloride,72572005210A,NDC,250,RC,,,,inpatient,1,GM,1.37,1.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gas Relief,57896079101B,NDC,250,RC,,,,inpatient,80,ML,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Synthroid,00074518211A,NDC,250,RC,,,,inpatient,75,GM,0.42,0.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Januvia,00006022128A,NDC,250,RC,,,,inpatient,25,ML,14.13,12.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Carvedilol,00904630361A,NDC,250,RC,,,,inpatient,25,ML,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
hydroCHLOROthiazide,51079077620A,NDC,250,RC,,,,inpatient,12.5,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
acetaZOLAMIDE,51672402201,NDC,250,RC,,,,inpatient,125,ML,1.57,1.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Atropine Sulfate,60505622600A,NDC,250,RC,,,,inpatient,1,EA,48.68,41.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
SandIMMUNE,00078024015,NDC,250,RC,,,,inpatient,25,ML,3.34,2.84,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nadolol,69238112409A,NDC,250,RC,,,,inpatient,40,ML,3.22,2.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
glyBURIDE,23155005701A,NDC,250,RC,,,,inpatient,2.5,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ALPRAZolam,51079078820A,NDC,250,RC,,,,inpatient,0.25,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
AndroGel,00051846230,NDC,250,RC,,,,inpatient,2.5,GM,20.26,17.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bacitracin,63323032931A,NDC,250,RC,,,,inpatient,50000,UN  ,3.71,3.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Labetalol HCl-Sodium Chloride,00143936501,NDC,250,RC,,,,inpatient,300,ML,39.84,33.86,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xifaxan,65649030303A,NDC,250,RC,,,,inpatient,550,ML,52.82,44.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Naloxone HCl,00409121501,NDC,250,RC,,,,inpatient,0.4,ML,14.6,12.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lisinopril,68001033300A,NDC,250,RC,,,,inpatient,5,ML,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PremierPro Rx ceFAZolin,25021010066A,NDC,250,RC,,,,inpatient,0.5,GM,5.17,4.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Atorvastatin Calcium,68084009901A,NDC,250,RC,,,,inpatient,40,ML,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Doxepin HCl,54838051240A,NDC,250,RC,,,,inpatient,10,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nitrofurantoin Macrocrystals,47781030701A,NDC,250,RC,,,,inpatient,50,ML,1.55,1.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
levoFLOXacin in 5% Dextrose,25021013281A,NDC,250,RC,,,,inpatient,250,ML,1.69,1.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vibramycin Calcium,00069097195,NDC,250,RC,,,,inpatient,50,ML,1.01,0.86,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Atorvastatin Calcium,68084059025A,NDC,250,RC,,,,inpatient,80,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
SUMAtriptan Succinate,65862014636A,NDC,250,RC,,,,inpatient,25,ML,0.44,0.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Milk Of Magnesia,00121043130B,NDC,250,RC,,,,inpatient,400,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nicotine Transdermal System,43598044770A,NDC,250,RC,,,,inpatient,14,ML,1.17,0.99,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sutent,00069055038,NDC,250,RC,,,,inpatient,12.5,ML,192.12,163.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00338004744,NDC,250,RC,,,,inpatient,1000,ML,3.21,2.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Montelukast Sodium AvPak,50268057415A,NDC,250,RC,,,,inpatient,5,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prenatal W/Iron,48433011201A,NDC,250,RC,,,,inpatient,1,EA,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluconazole,60760011301A,NDC,250,RC,,,,inpatient,150,ML,10.6,9.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
carBAMazepine,51672412401,NDC,250,RC,,,,inpatient,200,ML,0.83,0.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl (Premix),70594005603,NDC,250,RC,,,,inpatient,750,ML,9.36,7.96,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydrocortisone,00168002031,NDC,250,RC,,,,inpatient,1,EA,3,2.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amoxicillin,00143988980A,NDC,250,RC,,,,inpatient,250,ML,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Akten,17478079201,NDC,250,RC,,,,inpatient,1,EA,19.61,16.67,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
NOREPINEPHRINE-D5W 8 MG/250 ML (PRE,0270075470092103617,CDM,250,RC,,,,inpatient,8,ML,26.86,22.83,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Moexipril Hydrochloride,68462020801A,NDC,250,RC,,,,inpatient,15,ML,2.11,1.79,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
NIFEdipine,68084002201A,NDC,250,RC,,,,inpatient,10,ML,0.58,0.49,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Leucovorin Calcium,00054449911,NDC,250,RC,,,,inpatient,25,ML,5.73,4.87,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BSS,00065079515A,NDC,250,RC,,,,inpatient,1,EA,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Magnesium Sulfate,63323064250A,NDC,250,RC,,,,inpatient,25,GM,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tekturna,70839030030A,NDC,250,RC,,,,inpatient,300,ML,3.33,2.83,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetaminophen,00121197100A,NDC,250,RC,,,,inpatient,650,ML,1.37,1.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
levoFLOXacin,00904635161A,NDC,250,RC,,,,inpatient,250,ML,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose/NaCl/Potassium Chloride,00338067504,NDC,250,RC,,,,inpatient,40,UN  ,1.21,1.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Arixtra,67457059210,NDC,250,RC,,,,inpatient,2.5,ML,14.65,12.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ranolazine,27241012602A,NDC,250,RC,,,,inpatient,1000,ML,6.91,5.87,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Eplerenone,68084094825A,NDC,250,RC,,,,inpatient,25,ML,3.33,2.83,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clindamycin,63323028206A,NDC,250,RC,,,,inpatient,900,ML,3.72,3.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Domeboro,16500002324,NDC,250,RC,,,,inpatient,1.9,GM,0.74,0.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Leucovorin Calcium,00054449613,NDC,250,RC,,,,inpatient,5,ML,0.63,0.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tolterodine Tartrate,27241019130A,NDC,250,RC,,,,inpatient,2,ML,4.49,3.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Metoprolol Tartrate,62584026601A,NDC,250,RC,,,,inpatient,50,ML,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine,68462041820A,NDC,250,RC,,,,inpatient,1,EA,21.61,18.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Midazolam HCl,00409259605A,NDC,250,RC,,,,inpatient,50,ML,6.38,5.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nexterone,43066036020,NDC,250,RC,,,,inpatient,360,ML,43.76,37.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Marcaine with EPINEPHrine,00409174970,NDC,250,RC,,,,inpatient,10,ML,4.05,3.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Unasyn,00049001483B,NDC,250,RC,,,,inpatient,3,GM,3.27,2.78,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Terazosin HCl,59746038306A,NDC,250,RC,,,,inpatient,1,ML,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Betamethasone Dipropionate,00168005615A,NDC,250,RC,,,,inpatient,1,EA,42.04,35.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hespan,00264196510,NDC,250,RC,,,,inpatient,500,ML,10.99,9.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zonisamide,51079076820C,NDC,250,RC,,,,inpatient,100,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Furosemide,36000028425A,NDC,250,RC,,,,inpatient,100,ML,1.64,1.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Water For Irrigation,00338000403,NDC,250,RC,,,,inpatient,500,ML,0.93,0.79,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
HYDROmorphone HCl,00703011301,NDC,250,RC,,,,inpatient,50,ML,1.31,1.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Unasyn,00049001383A,NDC,250,RC,,,,inpatient,1.5,GM,1.32,1.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetylcysteine,63323069404A,NDC,250,RC,,,,inpatient,800,ML,3.9,3.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cefuroxime Axetil,68180030360,NDC,250,RC,,,,inpatient,500,ML,0.32,0.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amantadine HCl,68382051201A,NDC,250,RC,,,,inpatient,100,ML,0.64,0.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Famotidine,68001039800A,NDC,250,RC,,,,inpatient,40,ML,3.81,3.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PremierPro Rx Rocuronium Bromide,67457057410A,NDC,250,RC,,,,inpatient,100,ML,5.2,4.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Budesonide,00093681673,NDC,250,RC,,,,inpatient,1,EA,2.87,2.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amitriptyline HCl,29300042001A,NDC,250,RC,,,,inpatient,25,ML,0.26,0.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ketorolac Tromethamine,00409379301A,NDC,250,RC,,,,inpatient,15,ML,17.44,14.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetaminophen,45802073030A,NDC,250,RC,,,,inpatient,650,ML,0.5,0.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
levETIRAcetam,60505328006A,NDC,250,RC,,,,inpatient,500,ML,0.72,0.61,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ventolin HFA,00173068224A,NDC,250,RC,,,,inpatient,1,EA,21.2,18.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lithium Carbonate,00054002025A,NDC,250,RC,,,,inpatient,450,ML,0.46,0.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl Viscous,00054350049,NDC,250,RC,,,,inpatient,100,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,00409427701B,NDC,250,RC,,,,inpatient,400,ML,1.46,1.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl,67457034105A,NDC,250,RC,,,,inpatient,5,GM,51.24,43.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Strattera,00002322930,NDC,250,RC,,,,inpatient,40,ML,5.62,4.78,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Adderall XR,54092038301A,NDC,250,RC,,,,inpatient,10,ML,3.42,2.91,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00409113403A,NDC,250,RC,,,,inpatient,100,ML,7.5,6.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bethanechol Chloride,00832051200A,NDC,250,RC,,,,inpatient,25,ML,0.22,0.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
LORazepam,00641604425B,NDC,250,RC,,,,inpatient,2,ML,2.45,2.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PHENobarbital,13517069405A,NDC,250,RC,,,,inpatient,100,ML,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ancobon,00187355410,NDC,250,RC,,,,inpatient,250,ML,62.12,52.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
busPIRone HCl,51079098620A,NDC,250,RC,,,,inpatient,10,ML,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ARIPiprazole,60687017901A,NDC,250,RC,,,,inpatient,10,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
LORazepam,00093342510A,NDC,250,RC,,,,inpatient,0.5,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Meperidine HCl,00641605225,NDC,250,RC,,,,inpatient,25,ML,2.25,1.91,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PHENobarbital,00143145505A,NDC,250,RC,,,,inpatient,60,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Heartburn Relief,00904552952A,NDC,250,RC,,,,inpatient,10,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Rosuvastatin Calcium,27808015701A,NDC,250,RC,,,,inpatient,20,ML,5.02,4.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl (Premix),70594004402,NDC,250,RC,,,,inpatient,2000,ML,149.83,127.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Glucagen Diagnostic Kit,00597026010A,NDC,250,RC,,,,inpatient,1,ML,86.96,73.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Metoprolol Succinate,00904632461A,NDC,250,RC,,,,inpatient,100,ML,0.43,0.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00338002304,NDC,250,RC,,,,inpatient,1000,ML,2.68,2.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Viscoat,08065183905,NDC,250,RC,,,,inpatient,0.5,ML,59.53,50.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Venlafaxine HCl,00093738656,NDC,250,RC,,,,inpatient,150,ML,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Optiray 320,00019132373,NDC,250,RC,,,,inpatient,320,ML,1.38,1.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levemir,00169368712A,NDC,250,RC,,,,inpatient,100,UN  ,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexAMETHasone Intensol,00054317644,NDC,250,RC,,,,inpatient,1,ML,0.71,0.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
diphenhydrAMINE HCl,00904205661A,NDC,250,RC,,,,inpatient,50,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
oseltamivir phosphate,47781047013A,NDC,250,RC,,,,inpatient,75,ML,2.43,2.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cefuroxime Axetil,67877021560A,NDC,250,RC,,,,inpatient,250,ML,0.66,0.56,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Betamethasone Valerate,00472037115A,NDC,250,RC,,,,inpatient,1,EA,7.5,6.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Letrozole,00093762056A,NDC,250,RC,,,,inpatient,2.5,ML,0.59,0.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Isosorbide Dinitrate,00781169501A,NDC,250,RC,,,,inpatient,20,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lugol's Solution,48433023015A,NDC,250,RC,,,,inpatient,14,ML,17.2,14.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
DOPamine HCl-dextrose,00338100702,NDC,250,RC,,,,inpatient,400000,GM,9.23,7.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Heparin Lock Flush,64253033335G,NDC,250,RC,,,,inpatient,10,ML,1,0.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Caffeine Citrate,63323040703,NDC,250,RC,,,,inpatient,60,ML,16.12,13.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00409488810,NDC,250,RC,,,,inpatient,10,ML,0.44,0.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Naphcon-A,00065008515A,NDC,250,RC,,,,inpatient,1,EA,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methocarbamol,70010077001A,NDC,250,RC,,,,inpatient,750,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Intelence,59676057101,NDC,250,RC,,,,inpatient,200,ML,14.13,12.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Desmopressin Acetate,60505025801A,NDC,250,RC,,,,inpatient,0.2,ML,1.12,0.95,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Metoclopramide,00121157610,NDC,250,RC,,,,inpatient,10,ML,0.45,0.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Edurant,59676027801,NDC,250,RC,,,,inpatient,25,ML,35.27,29.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00019118827A,NDC,250,RC,,,,inpatient,10,ML,36.14,30.72,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Celecoxib,62332014131A,NDC,250,RC,,,,inpatient,100,ML,3.12,2.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Neostigmine Methylsulfate,63323041310A,NDC,250,RC,,,,inpatient,0.5,ML,14.1,11.99,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cyproheptadine HCl,00115175701A,NDC,250,RC,,,,inpatient,4,ML,0.47,0.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zolpidem Tartrate,68084018901A,NDC,250,RC,,,,inpatient,5,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
fluvoxaMINE Maleate,51079099220A,NDC,250,RC,,,,inpatient,50,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nystatin,00713067815A,NDC,250,RC,,,,inpatient,1,EA,8.53,7.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cyclomydril,00065035902,NDC,250,RC,,,,inpatient,1,EA,2.43,2.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Losartan Potassium,68084034601B,NDC,250,RC,,,,inpatient,25,ML,0.47,0.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Propranolol HCl,00228278011,NDC,250,RC,,,,inpatient,120,ML,1.89,1.61,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
lacosamide,67877073460,NDC,250,RC,,,,inpatient,100,ML,0.19,0.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Intelence,59676057001,NDC,250,RC,,,,inpatient,100,ML,7.62,6.48,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Varivax,00006482700,NDC,250,RC,,,,inpatient,0.5,ML,165.64,140.79,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Avodart,80725071215,NDC,250,RC,,,,inpatient,0.5,ML,0.35,0.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tobramycin Sulfate,39822041206,NDC,250,RC,,,,inpatient,1200,ML,149.06,126.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aztreonam,63323040120A,NDC,250,RC,,,,inpatient,1,GM,22.62,19.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tropicamide,61314035501,NDC,250,RC,,,,inpatient,3,ML,3.21,2.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Famotidine,68001039700A,NDC,250,RC,,,,inpatient,20,ML,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PARoxetine HCl,68084004601,NDC,250,RC,,,,inpatient,30,ML,0.69,0.59,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Stromectol,00006003220,NDC,250,RC,,,,inpatient,3,ML,3.57,3.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
valACYclovir HCl,31722070490A,NDC,250,RC,,,,inpatient,500,ML,1.01,0.86,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Duramorph,00641601910,NDC,250,RC,,,,inpatient,1,ML,13.04,11.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Metoprolol Succinate,60687040201A,NDC,250,RC,,,,inpatient,50,ML,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetaminophen,69367032304A,NDC,250,RC,,,,inpatient,160,ML,5.36,4.56,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Triamcinolone Acetonide,60432056161A,NDC,250,RC,,,,inpatient,1,EA,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Potassium Chl in Dextrose and Sodium Chl,00338080304,NDC,250,RC,,,,inpatient,20,UN  ,1.44,1.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Primaxin IV,00006351659,NDC,250,RC,,,,inpatient,500,ML,3.95,3.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tazicef,00409508411A,NDC,250,RC,,,,inpatient,2,GM,3.95,3.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Escitalopram,68084061701A,NDC,250,RC,,,,inpatient,10,ML,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Penicillin V Potassium,65862017601A,NDC,250,RC,,,,inpatient,500,ML,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BUPivacaine HCl with EPINEPHrine,00409904501,NDC,250,RC,,,,inpatient,10,ML,1.2,1.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Triamcinolone Acetonide,00168000415,NDC,250,RC,,,,inpatient,1,EA,0.8,0.68,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
methylPREDNISolone,59746000106A,NDC,250,RC,,,,inpatient,4,ML,0.91,0.77,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zithromax,00069315083B,NDC,250,RC,,,,inpatient,250,ML,6,5.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
levoFLOXacin in 5% Dextrose,25021013283A,NDC,250,RC,,,,inpatient,750,ML,12.82,10.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pred Mild,11980017405,NDC,250,RC,,,,inpatient,1,EA,144.9,123.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nitroglycerin,28595012049A,NDC,250,RC,,,,inpatient,1,EA,162.57,138.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Albuterol Sulfate,00487990425A,NDC,250,RC,,,,inpatient,1,EA,0.45,0.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pyrazinamide,70954048420A,NDC,250,RC,,,,inpatient,500,ML,2.08,1.77,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Folic Acid,10135018210A,NDC,250,RC,,,,inpatient,1,ML,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Perphenazine,64980029201A,NDC,250,RC,,,,inpatient,8,ML,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tikosyn,00069582043,NDC,250,RC,,,,inpatient,0.5,ML,4.11,3.49,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fleet Mineral Oil Enema,00132030140,NDC,250,RC,,,,inpatient,133,ML,1.77,1.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Typhim Vi,49281079051,NDC,250,RC,,,,inpatient,25,GM,95.64,81.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
QUEtiapine Fumarate,00904680361A,NDC,250,RC,,,,inpatient,200,ML,0.73,0.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Carvedilol,68084085401A,NDC,250,RC,,,,inpatient,6.25,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pramipexole Dihydrochloride,13668009490,NDC,250,RC,,,,inpatient,1,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Meclizine HCl,16571066001A,NDC,250,RC,,,,inpatient,12.5,ML,0.56,0.48,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nitroglycerin Transdermal System,00378910293,NDC,250,RC,,,,inpatient,0.1,ML,0.61,0.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Suboxone,12496120403,NDC,250,RC,,,,inpatient,1,EA,8.12,6.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cyanokit,50633031011A,NDC,250,RC,,,,inpatient,5,GM,810.19,688.66,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Brilinta,00186077739A,NDC,250,RC,,,,inpatient,90,ML,5.91,5.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Brevibloc,10019005561,NDC,250,RC,,,,inpatient,2500000,GM,130.99,111.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Piperacillin and Tazobactam,68001050831A,NDC,250,RC,,,,inpatient,4.5,GM,2.89,2.46,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Betamethasone Dipropionate,00472038145,NDC,250,RC,,,,inpatient,1,EA,60.32,51.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Magnesium Sulfate,63323010605,NDC,250,RC,,,,inpatient,2,GM,3.04,2.58,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levothyroxine Sodium,24201000201A,NDC,250,RC,,,,inpatient,100,GM,63,53.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Midazolam HCl,63323041112A,NDC,250,RC,,,,inpatient,1,ML,1.1,0.94,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
QUEtiapine Fumarate,16729009712A,NDC,250,RC,,,,inpatient,400,ML,0.32,0.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Imitrex,00173044902,NDC,250,RC,,,,inpatient,6,ML,3.23,2.75,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lyrica,00071101341A,NDC,250,RC,,,,inpatient,50,ML,8.14,6.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cephalexin AvPak,50268015215A,NDC,250,RC,,,,inpatient,500,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sensipar,55513007330A,NDC,250,RC,,,,inpatient,5,ML,2,1.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetaminophen,68094033059,NDC,250,RC,,,,inpatient,325,ML,0.81,0.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Suboxone,12496121203,NDC,250,RC,,,,inpatient,1,EA,15.49,13.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Keppra,50474000263,NDC,250,RC,,,,inpatient,500,ML,3.17,2.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ALPRAZolam,65862067801A,NDC,250,RC,,,,inpatient,1,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dipyridamole,64980013501A,NDC,250,RC,,,,inpatient,75,ML,0.39,0.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clinimix,00338108904,NDC,250,RC,,,,inpatient,2000,ML,77.79,66.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mineral Oil,48433020230A,NDC,250,RC,,,,inpatient,30,ML,0.01,0.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
lamoTRIgine,51672413304A,NDC,250,RC,,,,inpatient,200,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
rOPINIRole HCl,68462025301A,NDC,250,RC,,,,inpatient,0.25,ML,0.57,0.48,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nucynta,24510005010,NDC,250,RC,,,,inpatient,50,ML,5.1,4.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lyrica,00071101268,NDC,250,RC,,,,inpatient,25,ML,3.92,3.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Haloperidol Lactate,00121058105A,NDC,250,RC,,,,inpatient,2,ML,0.17,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
metroNIDAZOLE,00338105548A,NDC,250,RC,,,,inpatient,500,ML,0.97,0.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levothyroxine Sodium,00378180777,NDC,250,RC,,,,inpatient,88,GM,0.46,0.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ceFAZolin Sodium,60505074905B,NDC,250,RC,,,,inpatient,1,GM,0.58,0.49,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00338001703,NDC,250,RC,,,,inpatient,500,ML,1.5,1.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Neo-Polycin HC,00574414435A,NDC,250,RC,,,,inpatient,1,EA,2.94,2.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
paliperidone,47335076683A,NDC,250,RC,,,,inpatient,6,ML,9.33,7.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Heparin Lock Flush,64253033335E,NDC,250,RC,,,,inpatient,10,ML,1,0.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lisinopril,00904679861A,NDC,250,RC,,,,inpatient,10,ML,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
CARBOplatin,00703424401A,NDC,250,RC,,,,inpatient,50,ML,5.12,4.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Phosphate,00517340525Z,NDC,250,RC,,,,inpatient,20,EA,0.54,0.46,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cocaine HCl,00527197174A,NDC,250,RC,,,,inpatient,4,ML,260.14,221.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Escitalopram Oxalate,54838055170A,NDC,250,RC,,,,inpatient,5,ML,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BUPivacaine HCl,00409115902,NDC,250,RC,,,,inpatient,2.5,ML,1.65,1.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mag-Al Plus,00121176130A,NDC,250,RC,,,,inpatient,30,ML,0.44,0.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cephalexin,68180012101,NDC,250,RC,,,,inpatient,250,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Valsartan,55111073390A,NDC,250,RC,,,,inpatient,160,ML,0.41,0.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
S-2 Inhalant,00487590199,NDC,250,RC,,,,inpatient,1,ML,1.17,0.99,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Albuterol Sulfate,00378827093A,NDC,250,RC,,,,inpatient,1,EA,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Teflaro,00456040010,NDC,250,RC,,,,inpatient,400,ML,153.07,130.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Topamax,50458064265,NDC,250,RC,,,,inpatient,200,ML,8.89,7.56,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Polysporin,54868098600,NDC,250,RC,,,,inpatient,1,EA,4.2,3.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cefTRIAXone,00409733503B,NDC,250,RC,,,,inpatient,2,GM,2.68,2.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
metroNIDAZOLE,00338105548B,NDC,250,RC,,,,inpatient,250,ML,1.03,0.88,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluorouracil,63323011751,NDC,250,RC,,,,inpatient,2500,ML,6.41,5.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prezista,59676056201,NDC,250,RC,,,,inpatient,600,ML,23.63,20.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ampicillin Sodium,65219001410,NDC,250,RC,,,,inpatient,250,ML,0.69,0.59,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Thiotepa,25021024602A,NDC,250,RC,,,,inpatient,15,ML,99.66,84.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
SEROquel,00310027910A,NDC,250,RC,,,,inpatient,400,ML,1.22,1.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
quiNIDine Sulfate,00093917501,NDC,250,RC,,,,inpatient,300,ML,0.46,0.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Verapamil HCl,00591034501A,NDC,250,RC,,,,inpatient,120,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Bicarbonate,63323008305,NDC,250,RC,,,,inpatient,0.5,UN  ,16.13,13.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Phytonadione,70710101403A,NDC,250,RC,,,,inpatient,5,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexAMETHasone Sodium Phosphate,63323016505A,NDC,250,RC,,,,inpatient,20,ML,0.6,0.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
prednisoLONE Sodium Phosphate,50383004004,NDC,250,RC,,,,inpatient,5,ML,0.63,0.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prazosin HCl,00378110101A,NDC,250,RC,,,,inpatient,1,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cefTRIAXone,00409733503A,NDC,250,RC,,,,inpatient,2,GM,4.48,3.81,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Rivastigmine Tartrate,51991079606,NDC,250,RC,,,,inpatient,6,ML,0.17,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aspirin Low Dose,00904679489A,NDC,250,RC,,,,inpatient,81,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Digoxin,00641141035,NDC,250,RC,,,,inpatient,0.5,ML,3.53,3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methylergonovine Maleate,69238160508A,NDC,250,RC,,,,inpatient,0.2,ML,19.13,16.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Baraclude,00003161112,NDC,250,RC,,,,inpatient,0.5,ML,37.92,32.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Selegiline HCl,60505005501,NDC,250,RC,,,,inpatient,5,ML,1.59,1.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
chlorproMAZINE HCl,00641139835,NDC,250,RC,,,,inpatient,50,ML,7.03,5.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin K1,00409915701A,NDC,250,RC,,,,inpatient,1,ML,8.9,7.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Rivastigmine Tartrate,51991079406,NDC,250,RC,,,,inpatient,3,ML,0.22,0.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nabumetone,69097096607A,NDC,250,RC,,,,inpatient,750,ML,0.2,0.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nicotine Transdermal System,00536589488A,NDC,250,RC,,,,inpatient,7,ML,1.9,1.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Budesonide,00093681573,NDC,250,RC,,,,inpatient,1,EA,6.19,5.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Niacin,00904227260,NDC,250,RC,,,,inpatient,500,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lokelma,00310111030,NDC,250,RC,,,,inpatient,10,GM,4.38,3.72,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Allopurinol,55111073005A,NDC,250,RC,,,,inpatient,300,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Haloperidol,54838050115,NDC,250,RC,,,,inpatient,2,ML,1.18,1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tekturna,70839015030A,NDC,250,RC,,,,inpatient,150,ML,0.97,0.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydroxychloroquine Sulfate,68084026901C,NDC,250,RC,,,,inpatient,200,ML,2,1.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Latuda,63402030430,NDC,250,RC,,,,inpatient,40,ML,2.52,2.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
AzaSite,82584030703A,NDC,250,RC,,,,inpatient,1,EA,177.84,151.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Acetate,00409729973A,NDC,250,RC,,,,inpatient,40,UN  ,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calcium Acetate,68084047901A,NDC,250,RC,,,,inpatient,667,ML,0.71,0.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose/NaCl/Potassium Chloride,00338066904,NDC,250,RC,,,,inpatient,10,UN  ,2.32,1.97,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00338004911A,NDC,250,RC,,,,inpatient,50,ML,2.03,1.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clinimix,00338113303,NDC,250,RC,,,,inpatient,1000,ML,28.72,24.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Valproic Acid,00591401201A,NDC,250,RC,,,,inpatient,250,ML,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Estradiol,51862033401,NDC,250,RC,,,,inpatient,2,ML,0.21,0.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetylcysteine,63323096330A,NDC,250,RC,,,,inpatient,200,ML,200.99,170.84,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
OneLAX,71399788901A,NDC,250,RC,,,,inpatient,300,ML,1.53,1.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xifaxan,65649030103A,NDC,250,RC,,,,inpatient,200,ML,16.47,14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prochlorperazine Edisylate,23155029442A,NDC,250,RC,,,,inpatient,10,ML,0.94,0.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Curosurf,10122051001,NDC,250,RC,,,,inpatient,120,ML,375.66,319.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Doxazosin Mesylate,60505009500A,NDC,250,RC,,,,inpatient,4,ML,0.83,0.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lactulose,00121115440,NDC,250,RC,,,,inpatient,20,GM,0.46,0.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acyclovir,68084010701A,NDC,250,RC,,,,inpatient,200,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Thiosulfate,60267070550,NDC,250,RC,,,,inpatient,12.5,GM,89,75.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
VIAFLEX 500ML 1 EACH EACH,0269999750085412102,CDM,250,RC,,,,inpatient,1,EA,3.64,3.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Intralipid,00338051913A,NDC,250,RC,,,,inpatient,500,ML,10.14,8.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cyclopentolate HCl,24208073501,NDC,250,RC,,,,inpatient,1,EA,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sudogest,00904505359,NDC,250,RC,,,,inpatient,30,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Citalopram,00904608561A,NDC,250,RC,,,,inpatient,20,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cytomel,60793011501,NDC,250,RC,,,,inpatient,5,GM,0.78,0.66,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Duramorph,00641602010A,NDC,250,RC,,,,inpatient,5,ML,1.62,1.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bentyl,58914008052,NDC,250,RC,,,,inpatient,20,ML,58.67,49.87,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,00054350547,NDC,250,RC,,,,inpatient,50,ML,3.24,2.75,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
droNABinol,42858086706A,NDC,250,RC,,,,inpatient,2.5,ML,2.52,2.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Haloperidol Lactate,25021080601A,NDC,250,RC,,,,inpatient,5,ML,1.31,1.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ipratropium Bromide,00487980101,NDC,250,RC,,,,inpatient,1,EA,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ketamine HCl,67457000110A,NDC,250,RC,,,,inpatient,500,ML,7.52,6.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Leuprolide Acetate,00781400332A,NDC,250,RC,,,,inpatient,1,ML,90.18,76.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00487930133,NDC,250,RC,,,,inpatient,3,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lokelma,00310110530,NDC,250,RC,,,,inpatient,5,GM,4.94,4.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Arixtra,67457059508,NDC,250,RC,,,,inpatient,10,ML,35.48,30.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
SOLU-Medrol 125mg Vial,00009004722A,NDC,250,RC,,,,inpatient,125,ML,7.35,6.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dilTIAZem HCl,51079074520,NDC,250,RC,,,,inpatient,30,ML,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Addamel N,63323014397,NDC,250,RC,,,,inpatient,10,ML,13.67,11.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Benzoin Compound,00395024392A,NDC,250,RC,,,,inpatient,1,EA,2.14,1.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acyclovir Sodium,63323032510,NDC,250,RC,,,,inpatient,500,ML,0.31,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lovaza,69784042012,NDC,250,RC,,,,inpatient,1,GM,2.46,2.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydrocortisone Valerate,51672129001,NDC,250,RC,,,,inpatient,1,EA,0.57,0.48,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dipyridamole,00115107101A,NDC,250,RC,,,,inpatient,50,ML,0.31,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nevirapine,65862005724A,NDC,250,RC,,,,inpatient,50,ML,0.79,0.67,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexAMETHasone-Neomycin-Polymyxin,61314063006A,NDC,250,RC,,,,inpatient,1,EA,4,3.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Travasol,00338064406,NDC,250,RC,,,,inpatient,2000,ML,30.76,26.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Venlafaxine HCl,68084084401A,NDC,250,RC,,,,inpatient,37.5,ML,0.36,0.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Triamcinolone Acetonide,45802005435,NDC,250,RC,,,,inpatient,1,EA,0.25,0.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dipyridamole,00641256944A,NDC,250,RC,,,,inpatient,50,ML,3.41,2.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Midazolam HCl,72611074901A,NDC,250,RC,,,,inpatient,5,ML,1.32,1.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Disopyramide Phosphate,00093312901A,NDC,250,RC,,,,inpatient,150,ML,1.44,1.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
chlorproMAZINE HCl,68462086201A,NDC,250,RC,,,,inpatient,25,ML,1.01,0.86,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Samsca,59148002050,NDC,250,RC,,,,inpatient,15,ML,305.31,259.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pamidronate Disodium,61703032618A,NDC,250,RC,,,,inpatient,90,ML,19.63,16.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00338055118,NDC,250,RC,,,,inpatient,100,ML,3.22,2.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
risperiDONE,68084027201,NDC,250,RC,,,,inpatient,1,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Haloperidol,00832152011A,NDC,250,RC,,,,inpatient,1,ML,0.29,0.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PHENobarbital,13517062610A,NDC,250,RC,,,,inpatient,30,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hyoscyamine Sulfate,47781001201A,NDC,250,RC,,,,inpatient,0.125,ML,0.2,0.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ProSol,00338049906A,NDC,250,RC,,,,inpatient,2000,ML,70.62,60.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
glipiZIDE,64980028101A,NDC,250,RC,,,,inpatient,10,ML,0.32,0.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Verapamil HCl,00591034301,NDC,250,RC,,,,inpatient,80,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Verapamil HCl,68462029301A,NDC,250,RC,,,,inpatient,180,ML,0.16,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Erythromycin,45802003846,NDC,250,RC,,,,inpatient,1,EA,30.9,26.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zidovudine,65862004824A,NDC,250,RC,,,,inpatient,10,ML,9.66,8.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Glydo,25021067377,NDC,250,RC,,,,inpatient,11,ML,4.15,3.53,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,17478071130A,NDC,250,RC,,,,inpatient,1,EA,5.3,4.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nystatin,00093098301,NDC,250,RC,,,,inpatient,500000,UN  ,0.62,0.53,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
rifAMPin,68180065907A,NDC,250,RC,,,,inpatient,300,ML,0.17,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clinimix 8/10,00338018806,NDC,250,RC,,,,inpatient,1000,ML,35.78,30.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tobrex,00078081301,NDC,250,RC,,,,inpatient,1,EA,81.93,69.64,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Teflaro,00456060010,NDC,250,RC,,,,inpatient,600,ML,153.07,130.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
levETIRAcetam,68001011406A,NDC,250,RC,,,,inpatient,750,ML,0.49,0.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xarelto,50458057810,NDC,250,RC,,,,inpatient,15,ML,10.62,9.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xylocaine with EPINEPHrine,63323048357,NDC,250,RC,,,,inpatient,50,ML,2.6,2.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tranexamic Acid,81284061110A,NDC,250,RC,,,,inpatient,1000,ML,13.71,11.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
lacosamide,67877073295B,NDC,250,RC,,,,inpatient,50,ML,7.5,6.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Erythromycin,75834024330A,NDC,250,RC,,,,inpatient,500,ML,0.96,0.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Rocuronium Bromide,00781322095B,NDC,250,RC,,,,inpatient,250,ML,10,8.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Promethazine HCl,00641149635,NDC,250,RC,,,,inpatient,50,ML,1.25,1.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zinc Sulfate,57896086501,NDC,250,RC,,,,inpatient,220,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Atropine Sulfate,60219174903A,NDC,250,RC,,,,inpatient,1,EA,35.26,29.97,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
mitoMYcin,16729011638A,NDC,250,RC,,,,inpatient,40,ML,129.05,109.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
QUEtiapine Fumarate,47335090488A,NDC,250,RC,,,,inpatient,100,ML,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Leucovorin Calcium,63323063150,NDC,250,RC,,,,inpatient,500,ML,26.19,22.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Verapamil HCl,68462029201A,NDC,250,RC,,,,inpatient,120,ML,1.68,1.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
DEPO-Medrol,00009347503A,NDC,250,RC,,,,inpatient,80,ML,95.97,81.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Advanced Eye Relief Eye Wash,10119000252,NDC,250,RC,,,,inpatient,1,EA,3,2.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Naropin,63323028635A,NDC,250,RC,,,,inpatient,30,ML,1.29,1.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calcium Gluconate,75834017119A,NDC,250,RC,,,,inpatient,5000,ML,2.59,2.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
predniSONE,59746017310A,NDC,250,RC,,,,inpatient,10,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xarelto,50458058010,NDC,250,RC,,,,inpatient,10,ML,11.67,9.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BACITRACIN/POLYMYXIN B SULFATE 10 G,0269940458232040331A,CDM,250,RC,,,,inpatient,1,EA,8.42,7.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lyrica,00071101541,NDC,250,RC,,,,inpatient,100,ML,8.14,6.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
guaiFENesin DM,00121127600A,NDC,250,RC,,,,inpatient,10,ML,0.6,0.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nitroglycerin-Dextrose,00338104902,NDC,250,RC,,,,inpatient,50,ML,7.55,6.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Promethazine DM,71205065404A,NDC,250,RC,,,,inpatient,5,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Spironolactone,16729022501A,NDC,250,RC,,,,inpatient,25,ML,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Anbesol Maximum Strength,00573022567,NDC,250,RC,,,,inpatient,1,EA,5.52,4.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Imipramine HCl,49884005501A,NDC,250,RC,,,,inpatient,25,ML,0.22,0.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Detrol,00009454402,NDC,250,RC,,,,inpatient,2,ML,4.12,3.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl,67457082399,NDC,250,RC,,,,inpatient,1250,ML,9.25,7.86,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ciprofloxacin HCl,61314065605,NDC,250,RC,,,,inpatient,1,EA,0.81,0.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
fentaNYL Citrate,00409909422A,NDC,250,RC,,,,inpatient,100,GM,0.6,0.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00338055311,NDC,250,RC,,,,inpatient,50,ML,3.22,2.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clindamycin Phosphate-Dextrose,00338341024A,NDC,250,RC,,,,inpatient,300,ML,2.95,2.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Venlafaxine HCl,68084070901A,NDC,250,RC,,,,inpatient,75,ML,0.42,0.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Infants Mylicon,62372063015A,NDC,250,RC,,,,inpatient,40,ML,1.33,1.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
acetaZOLAMIDE,51672402301,NDC,250,RC,,,,inpatient,250,ML,0.38,0.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ceFAZolin Sodium,60505074905A,NDC,250,RC,,,,inpatient,1,GM,5.17,4.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nimbex,00074438010,NDC,250,RC,,,,inpatient,20,ML,22.64,19.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Betadine,67618015004,NDC,250,RC,,,,inpatient,1,EA,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
CARBOplatin,61703033950A,NDC,250,RC,,,,inpatient,450,ML,20.82,17.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
M-M-R II,00006468100,NDC,250,RC,,,,inpatient,0.5,ML,83.04,70.58,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Enalapril Maleate,60760058730A,NDC,250,RC,,,,inpatient,5,ML,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00338055318A,NDC,250,RC,,,,inpatient,100,ML,3.22,2.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
risperiDONE,68084027301,NDC,250,RC,,,,inpatient,2,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
OLANZapine,60505311200A,NDC,250,RC,,,,inpatient,7.5,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
VIAFLEX 2000 ML 1 EACH EACH,0269999850085412133,CDM,250,RC,,,,inpatient,1,EA,4.68,3.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cefTRIAXone,25021010610B,NDC,250,RC,,,,inpatient,1,GM,1.28,1.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Colchicine,00143301830,NDC,250,RC,,,,inpatient,0.6,ML,4.05,3.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
levoFLOXacin,72578009918A,NDC,250,RC,,,,inpatient,500,ML,0.27,0.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
traZODone Hydrochloride,50111045001A,NDC,250,RC,,,,inpatient,150,ML,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cefTRIAXone,00409733701A,NDC,250,RC,,,,inpatient,250,ML,0.63,0.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Coreg CR,80725038713,NDC,250,RC,,,,inpatient,40,ML,5.18,4.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dilTIAZem HCl,68682000810,NDC,250,RC,,,,inpatient,90,ML,0.22,0.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00338004902,NDC,250,RC,,,,inpatient,250,ML,0.65,0.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl (Premix),70594004203,NDC,250,RC,,,,inpatient,1000,ML,13.04,11.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
DEPO-Medrol,00009307303A,NDC,250,RC,,,,inpatient,40,ML,4.92,4.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dyrenium,59212000201,NDC,250,RC,,,,inpatient,50,ML,2.17,1.84,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Colchicine,60687035825B,NDC,250,RC,,,,inpatient,0.6,ML,5.32,4.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
buPROPion HCl,00378043301,NDC,250,RC,,,,inpatient,75,ML,0.77,0.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Potassium Acetate,51754200104A,NDC,250,RC,,,,inpatient,40,UN  ,2.38,2.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
metFORMIN HCl,62756014301A,NDC,250,RC,,,,inpatient,750,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00054023624A,NDC,250,RC,,,,inpatient,30,ML,1.22,1.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Testosterone,45802028103,NDC,250,RC,,,,inpatient,1.25,GM,3.59,3.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,00409427501A,NDC,250,RC,,,,inpatient,5,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Renvela,58468013301,NDC,250,RC,,,,inpatient,800,ML,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Naphazoline HCl,17478021612,NDC,250,RC,,,,inpatient,1,EA,0.01,0.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Homatropine Hbr,54799043105B,NDC,250,RC,,,,inpatient,1,EA,35.07,29.81,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Azithromycin,59762305102,NDC,250,RC,,,,inpatient,1,GM,12.92,10.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hyoscyamine Sulfate,47781001301,NDC,250,RC,,,,inpatient,0.125,ML,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zidovudine,65862010701A,NDC,250,RC,,,,inpatient,100,ML,3.77,3.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Entacapone,51079027303A,NDC,250,RC,,,,inpatient,200,ML,0.4,0.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Probenecid,00378015601,NDC,250,RC,,,,inpatient,500,ML,0.51,0.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00338004304,NDC,250,RC,,,,inpatient,1000,ML,0.93,0.79,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Wellbutrin XL,52959082060A,NDC,250,RC,,,,inpatient,300,ML,1.02,0.87,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sulfacetamide Sodium,24208067004,NDC,250,RC,,,,inpatient,1,EA,32.86,27.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ceFAZolin,60505623105,NDC,250,RC,,,,inpatient,2,GM,4.29,3.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Diclofenac Sodium,16571020150A,NDC,250,RC,,,,inpatient,75,ML,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pilocarpine HCl,61314020415,NDC,250,RC,,,,inpatient,1,EA,76.49,65.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Terazosin HCl,59746038406A,NDC,250,RC,,,,inpatient,2,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nitroglycerin Transdermal System,00378910493A,NDC,250,RC,,,,inpatient,0.2,ML,0.41,0.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
diazePAM,00409127332A,NDC,250,RC,,,,inpatient,10,ML,2.41,2.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Donepezil HCl,00904647761A,NDC,250,RC,,,,inpatient,5,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mucinex,68084057201A,NDC,250,RC,,,,inpatient,600,ML,0.67,0.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00223176001,NDC,250,RC,,,,inpatient,1,GM,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ethambutol HCl,68180028101A,NDC,250,RC,,,,inpatient,400,ML,0.82,0.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl,63323028420D,NDC,250,RC,,,,inpatient,1000,ML,3.85,3.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pradaxa,00597035556A,NDC,250,RC,,,,inpatient,75,ML,4.42,3.76,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
SPS Suspension,46287000660,NDC,250,RC,,,,inpatient,15,GM,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zemplar,00074165801,NDC,250,RC,,,,inpatient,5,GM,14.8,12.58,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Phenylephrine HCl,70756061430A,NDC,250,RC,,,,inpatient,1,EA,0.83,0.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cefTRIAXone,25021010610A,NDC,250,RC,,,,inpatient,1,GM,2.59,2.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Preparation H,00573288320A,NDC,250,RC,,,,inpatient,1,EA,0.91,0.77,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Melatonin,74312015745,NDC,250,RC,,,,inpatient,5,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Docusate Sodium,00904718361A,NDC,250,RC,,,,inpatient,100,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Glycopyrrolate,00517460125A,NDC,250,RC,,,,inpatient,0.2,ML,1.85,1.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tolnaftate,45802070111,NDC,250,RC,,,,inpatient,1,EA,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Synthroid,00074714811,NDC,250,RC,,,,inpatient,200,GM,0.22,0.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
solifenacin succinate,67877052730A,NDC,250,RC,,,,inpatient,5,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
risperiDONE,23155031751A,NDC,250,RC,,,,inpatient,1,ML,0.49,0.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Asmanex Twisthaler,78206011501A,NDC,250,RC,,,,inpatient,1,EA,160.93,136.79,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Stratuscare Adult Glycerin Suppositories,58980041012A,NDC,250,RC,,,,inpatient,1,EA,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Meropenem,63323050720A,NDC,250,RC,,,,inpatient,500,ML,1.48,1.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00338004904,NDC,250,RC,,,,inpatient,1000,ML,2.25,1.91,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Verapamil HCl,51079091720,NDC,250,RC,,,,inpatient,120,ML,1.12,0.95,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Metoprolol Succinate,45963067811A,NDC,250,RC,,,,inpatient,200,ML,1.94,1.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Triamcinolone Acetonide,00168000315,NDC,250,RC,,,,inpatient,1,EA,0.74,0.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ramipril,68001043000A,NDC,250,RC,,,,inpatient,5,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
carBAMazepine,00121094794A,NDC,250,RC,,,,inpatient,100,ML,3.02,2.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Glimepiride,68084032601A,NDC,250,RC,,,,inpatient,2,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Homatropine Hbr,54799043105A,NDC,250,RC,,,,inpatient,1,EA,35.05,29.79,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Provocholine,64281010006,NDC,250,RC,,,,inpatient,100,ML,2.34,1.99,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Warfarin Sodium,65162076811A,NDC,250,RC,,,,inpatient,7.5,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nitro-Bid,00281032608,NDC,250,RC,,,,inpatient,1,EA,1.95,1.66,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bisacodyl,00904640761A,NDC,250,RC,,,,inpatient,5,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Propylthiouracil,68084096425A,NDC,250,RC,,,,inpatient,50,ML,1.27,1.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methadone HCl,00406575562B,NDC,250,RC,,,,inpatient,5,ML,0.22,0.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00409189620A,NDC,250,RC,,,,inpatient,1000,ML,7.5,6.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Triamcinolone Acetonide,00168000480,NDC,250,RC,,,,inpatient,1,EA,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Celecoxib,00904650361A,NDC,250,RC,,,,inpatient,200,ML,1.55,1.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Keppra,50474000148,NDC,250,RC,,,,inpatient,500,ML,0.3,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pyridoxine HCl,63323018001,NDC,250,RC,,,,inpatient,100,ML,7.9,6.72,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bethanechol Chloride,65162057110,NDC,250,RC,,,,inpatient,5,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Empty Evacuated Container,00074161403,NDC,250,RC,,,,inpatient,1,UN  ,16.64,14.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Metoclopramide HCl,60687063101A,NDC,250,RC,,,,inpatient,10,ML,0.24,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
OXYTOCIN 20 UNITS in D5W-LR 1000 ML,0269883271285603101A,CDM,250,RC,,,,inpatient,20,UN  ,7.8,6.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,00409427801,NDC,250,RC,,,,inpatient,5,ML,3.71,3.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Diskets Dispersible,00054453825,NDC,250,RC,,,,inpatient,40,ML,0.2,0.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Primidone,00527130101,NDC,250,RC,,,,inpatient,50,ML,0.61,0.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Midazolam HCl,00409230801,NDC,250,RC,,,,inpatient,5,ML,0.81,0.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BUPivacaine HCl,00409116501,NDC,250,RC,,,,inpatient,10,ML,0.46,0.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calcitriol,00054000713,NDC,250,RC,,,,inpatient,0.25,GM,1.11,0.94,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
HYDROmorphone HCl,00409130431,NDC,250,RC,,,,inpatient,4,ML,1.16,0.99,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Itraconazole,67877045430A,NDC,250,RC,,,,inpatient,100,ML,5.6,4.76,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prochlorperazine,00713013512,NDC,250,RC,,,,inpatient,25,ML,2.12,1.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Good Neighbor Pharmacy Glucose,87701042598A,NDC,250,RC,,,,inpatient,4,GM,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Topiramate,68084034401A,NDC,250,RC,,,,inpatient,100,ML,0.38,0.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
fluPHENAZine HCl,00121065402,NDC,250,RC,,,,inpatient,2.5,ML,0.37,0.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dilantin,00071036924A,NDC,250,RC,,,,inpatient,100,ML,1.21,1.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vimpat,00131248035,NDC,250,RC,,,,inpatient,200,ML,15.64,13.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00338004303,NDC,250,RC,,,,inpatient,500,ML,0.73,0.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dificid,52015008001,NDC,250,RC,,,,inpatient,200,ML,234.67,199.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cilostazol,00093206406A,NDC,250,RC,,,,inpatient,100,ML,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mouthkote,50930009802,NDC,250,RC,,,,inpatient,1,EA,5.07,4.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sucralfate AvPak,50268073212A,NDC,250,RC,,,,inpatient,1,GM,0.38,0.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Quinapril,43547041309A,NDC,250,RC,,,,inpatient,40,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Isosulfan Blue,67457022005,NDC,250,RC,,,,inpatient,50,ML,1041.87,885.59,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xylocaine-MPF with EPINEPHrine,63323048917,NDC,250,RC,,,,inpatient,10,ML,3.36,2.86,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Propranolol HCl,00603548321A,NDC,250,RC,,,,inpatient,20,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ondansetron HCl,57237007530A,NDC,250,RC,,,,inpatient,4,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Glycopyrrolate,49884006601A,NDC,250,RC,,,,inpatient,2,ML,0.39,0.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clindamycin,63323028204,NDC,250,RC,,,,inpatient,600,ML,1.98,1.68,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methotrexate,67457022110A,NDC,250,RC,,,,inpatient,2,ML,5.13,4.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ceFAZolin,00781345295,NDC,250,RC,,,,inpatient,10,GM,6.82,5.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Brilinta,00186077660,NDC,250,RC,,,,inpatient,60,ML,5.88,5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Betadine,00065041130A,NDC,250,RC,,,,inpatient,1,EA,11.4,9.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00409490234,NDC,250,RC,,,,inpatient,25,GM,8.85,7.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Timolol Maleate,61314022705A,NDC,250,RC,,,,inpatient,1,EA,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Glucotrol XL,00049017402,NDC,250,RC,,,,inpatient,5,ML,0.6,0.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
levETIRAcetam,00378561505A,NDC,250,RC,,,,inpatient,500,ML,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
azaTHIOprine,68382000305A,NDC,250,RC,,,,inpatient,50,ML,0.35,0.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Meropenem,63323050720B,NDC,250,RC,,,,inpatient,500,ML,13.72,11.66,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clindamycin Phosphate-Dextrose,00338361224a,NDC,250,RC,,,,inpatient,600,ML,6.19,5.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
CISplatin,63323010365A,NDC,250,RC,,,,inpatient,100,ML,11.19,9.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nitrostat,00071041813,NDC,250,RC,,,,inpatient,0.4,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
SUMAtriptan Succinate,63304009819A,NDC,250,RC,,,,inpatient,50,ML,0.69,0.59,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
QUEtiapine Fumarate,67877024201A,NDC,250,RC,,,,inpatient,25,ML,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,76329191201A,NDC,250,RC,,,,inpatient,30,ML,6.62,5.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levobunolol HCl,24208050505A,NDC,250,RC,,,,inpatient,1,EA,0.21,0.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Anastrozole,60687011221A,NDC,250,RC,,,,inpatient,1,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
QUEtiapine Fumarate,60687036001A,NDC,250,RC,,,,inpatient,200,ML,0.31,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin B6,10006070012A,NDC,250,RC,,,,inpatient,50,ML,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cefepime,00264319511,NDC,250,RC,,,,inpatient,2,GM,16.22,13.79,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Phenylephrine HCl,00641614225C,NDC,250,RC,,,,inpatient,50000,GM,30,25.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
diphenhydrAMINE HCl,00121097800,NDC,250,RC,,,,inpatient,25,ML,2,1.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Belbuca,59385002460,NDC,250,RC,,,,inpatient,450,GM,12.11,10.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Chloraseptic,78112001103,NDC,250,RC,,,,inpatient,1,EA,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hepatamine,00264937155,NDC,250,RC,,,,inpatient,500,ML,55.56,47.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Good Neighbor Pharmacy Earwax Removal,46122055605A,NDC,250,RC,,,,inpatient,1,EA,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clopidogrel,68084053601A,NDC,250,RC,,,,inpatient,75,ML,0.21,0.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00409189301A,NDC,250,RC,,,,inpatient,10,ML,2.2,1.87,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levalbuterol,00115993178A,NDC,250,RC,,,,inpatient,0.63,ML,1.43,1.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methadone HCl,67457021720A,NDC,250,RC,,,,inpatient,10,ML,9.97,8.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xylocaine-MPF with EPINEPHrine,63323048737,NDC,250,RC,,,,inpatient,30,ML,2.79,2.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tazicef,00409508216,NDC,250,RC,,,,inpatient,1,GM,3.71,3.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tarceva,50242006201,NDC,250,RC,,,,inpatient,25,ML,46.01,39.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
OXcarbazepine,65162064978B,NDC,250,RC,,,,inpatient,300,ML,2.52,2.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Demerol Hydrochloride,00409117930,NDC,250,RC,,,,inpatient,75,ML,4.81,4.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Simple Syrup,00395266116,NDC,250,RC,,,,inpatient,480,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
DOXOrubicin HCl,00069303020A,NDC,250,RC,,,,inpatient,10,ML,3.45,2.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ziprasidone HCl,00904627208A,NDC,250,RC,,,,inpatient,80,ML,11.63,9.89,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Triamcinolone Acetonide,45802005535A,NDC,250,RC,,,,inpatient,1,EA,0.74,0.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mepron,00173054700,NDC,250,RC,,,,inpatient,750,ML,28.3,24.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calamine Lotion,00904253321A,NDC,250,RC,,,,inpatient,1,EA,3.08,2.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Naltrexone HCl,00406117003A,NDC,250,RC,,,,inpatient,50,ML,1.93,1.64,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Chloroprocaine HCl,00143920910,NDC,250,RC,,,,inpatient,20,ML,11.8,10.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Labetalol HCl,68001038203A,NDC,250,RC,,,,inpatient,200,ML,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Eye Drops,00536121794A,NDC,250,RC,,,,inpatient,1,EA,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Doxycycline Hyclate,62584069311A,NDC,250,RC,,,,inpatient,100,ML,0.49,0.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amitriptyline HCl,51079013320,NDC,250,RC,,,,inpatient,50,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Plan B One-Step,69536016288A,NDC,250,RC,,,,inpatient,1.5,ML,11.41,9.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Verapamil HCl,00409114405A,NDC,250,RC,,,,inpatient,2.5,ML,80.8,68.68,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Namenda,00456320563,NDC,250,RC,,,,inpatient,5,ML,3.05,2.59,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexmedeTOMIDine HCl-Sodium Chloride,00338955712,NDC,250,RC,,,,inpatient,400,GM,16.82,14.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00641607025,NDC,250,RC,,,,inpatient,10,ML,1.66,1.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin K1,00409915801,NDC,250,RC,,,,inpatient,10,ML,42.94,36.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Codeine Sulfate,00054024424,NDC,250,RC,,,,inpatient,30,ML,0.76,0.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nortriptyline HCl AvPak,50268060415A,NDC,250,RC,,,,inpatient,25,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
oxyBUTYnin Chloride,69315018210A,NDC,250,RC,,,,inpatient,5,ML,0.34,0.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mercaptopurine,00054458111,NDC,250,RC,,,,inpatient,50,ML,0.82,0.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Diclofenac Sodium,61314001425A,NDC,250,RC,,,,inpatient,1,EA,5.32,4.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Penicillin G Procaine,60793013010,NDC,250,RC,,,,inpatient,600000,UN  ,39.6,33.66,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Azithromycin,59762312001,NDC,250,RC,,,,inpatient,200,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ertapenem,72266015905A,NDC,250,RC,,,,inpatient,1,GM,21.88,18.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Naropin,63323028605,NDC,250,RC,,,,inpatient,100,ML,3.5,2.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ciprofloxacin HCl,61314065625,NDC,250,RC,,,,inpatient,1,EA,4.23,3.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydrocortisone Plus,24385002103A,NDC,250,RC,,,,inpatient,1,EA,1.33,1.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xylocaine-MPF with EPINEPHrine,63323048927,NDC,250,RC,,,,inpatient,20,ML,16.86,14.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl-Dextrose,00264959420,NDC,250,RC,,,,inpatient,4,ML,2.69,2.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
RisperDAL Consta,50458030711,NDC,250,RC,,,,inpatient,37.5,ML,399.34,339.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Senna,48433021940,NDC,250,RC,,,,inpatient,8.8,ML,1.55,1.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Selzentry,49702022318B,NDC,250,RC,,,,inpatient,150,ML,17.61,14.97,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Avycaz,00456270010,NDC,250,RC,,,,inpatient,2.5,GM,358.73,304.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Retacrit,00069131810A,NDC,250,RC,,,,inpatient,20000,UN  ,318.44,270.67,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Doxazosin Mesylate,60505009600A,NDC,250,RC,,,,inpatient,8,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Warfarin Sodium,65162076211A,NDC,250,RC,,,,inpatient,2,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sertraline HCl,60687023101A,NDC,250,RC,,,,inpatient,25,ML,0.25,0.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Buprenorphine,60687048121A,NDC,250,RC,,,,inpatient,2,ML,5.34,4.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Chlorthalidone,00378021301,NDC,250,RC,,,,inpatient,50,ML,0.19,0.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PHYSostigmine Salicylate,17478051002,NDC,250,RC,,,,inpatient,2,ML,2.04,1.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Neut,00409660902,NDC,250,RC,,,,inpatient,2.4,UN  ,6.03,5.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Heparin Sodium,63323054011,NDC,250,RC,,,,inpatient,1000,UN  ,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Glycopyrrolate,00517460225A,NDC,250,RC,,,,inpatient,1,ML,10.72,9.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acamprosate Calcium,51079024106A,NDC,250,RC,,,,inpatient,333,ML,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cefepime,00264319311,NDC,250,RC,,,,inpatient,1,GM,11.04,9.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ciprofloxacin,68084007001A,NDC,250,RC,,,,inpatient,500,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,76329301305A,NDC,250,RC,,,,inpatient,100,ML,3.03,2.58,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fleet Enema,00132020140A,NDC,250,RC,,,,inpatient,133,ML,1.33,1.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Uloric,64764091830,NDC,250,RC,,,,inpatient,40,ML,1.02,0.87,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Inderal LA,62559052001A,NDC,250,RC,,,,inpatient,60,ML,0.43,0.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Potassium Chl/Lactated Ringers/Dextrose,00338081104,NDC,250,RC,,,,inpatient,20,UN  ,1.44,1.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calcium Chloride,00409492834,NDC,250,RC,,,,inpatient,1,GM,8.02,6.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levothyroxine Sodium,51079044320,NDC,250,RC,,,,inpatient,125,GM,0.29,0.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Istalol,67425000312A,NDC,250,RC,,,,inpatient,0.3,ML,55.84,47.46,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Protamine Sulfate,63323022905,NDC,250,RC,,,,inpatient,50,ML,1.46,1.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Verapamil HCl,00591288201,NDC,250,RC,,,,inpatient,180,ML,1.03,0.88,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetylcysteine,63323069030B,NDC,250,RC,,,,inpatient,200,ML,39.32,33.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cefepime,25021012120B,NDC,250,RC,,,,inpatient,1,GM,3.21,2.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Adrenalin,42023010301,NDC,250,RC,,,,inpatient,30,ML,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ampicillin Sodium,00781340995,NDC,250,RC,,,,inpatient,10,GM,46.34,39.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nitroglycerin-Dextrose,00338104702,NDC,250,RC,,,,inpatient,25,ML,86.16,73.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Indomethacin,68462040601A,NDC,250,RC,,,,inpatient,25,ML,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amiodarone HCl,68084037101A,NDC,250,RC,,,,inpatient,200,ML,0.52,0.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
metFORMIN HCl,70010006310A,NDC,250,RC,,,,inpatient,500,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
amLODIPine Besylate,00904636961A,NDC,250,RC,,,,inpatient,2.5,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ketorolac Tromethamine,63323016202A,NDC,250,RC,,,,inpatient,60,ML,0.56,0.48,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vfend I.V.,00049319028,NDC,250,RC,,,,inpatient,200,ML,48.6,41.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Warfarin Sodium,65162076910A,NDC,250,RC,,,,inpatient,10,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluconazole,68462010130A,NDC,250,RC,,,,inpatient,50,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PHENobarbital,00603150858A,NDC,250,RC,,,,inpatient,20,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Neoral,00078024615,NDC,250,RC,,,,inpatient,25,ML,0.49,0.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Octreotide Acetate,67457024501A,NDC,250,RC,,,,inpatient,100,GM,4.97,4.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gemcitabine,00409018101,NDC,250,RC,,,,inpatient,1000,ML,9.13,7.76,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Children's Benadryl Allergy,50580053404,NDC,250,RC,,,,inpatient,12.5,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
NovoLOG,00169750111A,NDC,250,RC,,,,inpatient,1,ML,0.41,0.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Isopto Hyoscine,00998033105,NDC,250,RC,,,,inpatient,1,EA,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Isosorbide Dinitrate,68084008201A,NDC,250,RC,,,,inpatient,10,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Haloperidol Decanoate,63323047105,NDC,250,RC,,,,inpatient,100,ML,120.46,102.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sotradecol,67457016202,NDC,250,RC,,,,inpatient,10,ML,30.53,25.95,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ryanodex,42367054032,NDC,250,RC,,,,inpatient,250,ML,1833.02,1558.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tobramycin Sulfate,63323030602A,NDC,250,RC,,,,inpatient,80,ML,1.37,1.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gabapentin,65162010310A,NDC,250,RC,,,,inpatient,400,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Latuda,63402030230,NDC,250,RC,,,,inpatient,20,ML,38.7,32.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
AMINO ACIDS/PROTEIN HYDROLYS 30 ML,0270049294688001476,CDM,250,RC,,,,inpatient,30,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Albuterol Sulfate,00487990130,NDC,250,RC,,,,inpatient,1,EA,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Venlafaxine HCl,68084069801A,NDC,250,RC,,,,inpatient,37.5,ML,0.32,0.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Duovisc,08065183150A,NDC,250,RC,,,,inpatient,1,EA,249.72,212.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Estradiol Valerate,00517044001A,NDC,250,RC,,,,inpatient,200,ML,102.76,87.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Venclexta,00074056111,NDC,250,RC,,,,inpatient,10,ML,9.76,8.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
levETIRAcetam,51079082020A,NDC,250,RC,,,,inpatient,250,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Erythromycin,66267009028A,NDC,250,RC,,,,inpatient,250,ML,4.84,4.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cancidas,00006382310,NDC,250,RC,,,,inpatient,70,ML,41.37,35.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Theo-24,52244010010,NDC,250,RC,,,,inpatient,100,ML,3.32,2.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ezetimibe,59651005205A,NDC,250,RC,,,,inpatient,10,ML,1.81,1.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
VisionBlue,68803061210,NDC,250,RC,,,,inpatient,0.5,ML,527,447.95,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vimpat,00131181067,NDC,250,RC,,,,inpatient,200,ML,14.57,12.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Magnesium Sulfate,44567042424A,NDC,250,RC,,,,inpatient,4,GM,7.03,5.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Unasyn,00049001383,NDC,250,RC,,,,inpatient,1.5,GM,1.49,1.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Adrenalin,42023016801,NDC,250,RC,,,,inpatient,30,ML,198.17,168.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Carvedilol,00904630261A,NDC,250,RC,,,,inpatient,12.5,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Midazolam HCl,63323041110,NDC,250,RC,,,,inpatient,1,ML,2.88,2.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
OLANZapine,68084052501A,NDC,250,RC,,,,inpatient,2.5,ML,0.24,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
clonazePAM,51079088320,NDC,250,RC,,,,inpatient,2,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dapsone,49938010230,NDC,250,RC,,,,inpatient,25,ML,0.86,0.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose-Sodium Chloride,00264761200,NDC,250,RC,,,,inpatient,1000,ML,0.99,0.84,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
chlordiazePOXIDE HCl,00555003302A,NDC,250,RC,,,,inpatient,10,ML,0.46,0.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gebauer's Ethyl Chloride,00386000104,NDC,250,RC,,,,inpatient,1,EA,0.31,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Betamethasone Dipropionate,51672134004A,NDC,250,RC,,,,inpatient,1,EA,65.92,56.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
QUEtiapine Fumarate,68001059906A,NDC,250,RC,,,,inpatient,150,ML,12.35,10.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amantadine HCl,00121064616A,NDC,250,RC,,,,inpatient,50,ML,1.42,1.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
LORazepam,00641604525,NDC,250,RC,,,,inpatient,4,ML,0.86,0.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amoxicillin,57237003001A,NDC,250,RC,,,,inpatient,250,ML,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tolterodine Tartrate,51079019803A,NDC,250,RC,,,,inpatient,4,ML,5.38,4.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prostin E2,00009082703,NDC,250,RC,,,,inpatient,20,ML,1413.29,1201.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
fluPHENAZine HCl,00527178801,NDC,250,RC,,,,inpatient,1,ML,2.35,2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ampicillin Sodium,65219002023,NDC,250,RC,,,,inpatient,2,GM,3.29,2.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydrocortisone/Neomycin/Polymyxin B,24208063562,NDC,250,RC,,,,inpatient,1,EA,71.14,60.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xylocaine-MPF,63323049507,NDC,250,RC,,,,inpatient,20,ML,3.38,2.87,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ursodiol,60687010001A,NDC,250,RC,,,,inpatient,300,ML,2.19,1.86,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Allopurinol,51079020520,NDC,250,RC,,,,inpatient,100,ML,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Perphenazine,00603506121,NDC,250,RC,,,,inpatient,4,ML,0.89,0.76,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
amLODIPine Besylate,00904637161A,NDC,250,RC,,,,inpatient,10,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
hydrOXYzine HCl,00517560125,NDC,250,RC,,,,inpatient,50,ML,9.24,7.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bystolic,00456140230A,NDC,250,RC,,,,inpatient,2.5,ML,2.78,2.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xeloda,00004110020,NDC,250,RC,,,,inpatient,150,ML,7.58,6.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Furosemide,51079007220A,NDC,250,RC,,,,inpatient,20,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
risperiDONE,13668003605A,NDC,250,RC,,,,inpatient,0.5,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Atorvastatin Calcium,51079020820A,NDC,250,RC,,,,inpatient,10,ML,0.17,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tamoxifen Citrate,59651029960A,NDC,250,RC,,,,inpatient,10,ML,0.41,0.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
LORazepam,00904600961,NDC,250,RC,,,,inpatient,2,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sterile Water for Injection,00990711807A,NDC,250,RC,,,,inpatient,2000,ML,6.98,5.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
hydroCHLOROthiazide,29300012901A,NDC,250,RC,,,,inpatient,50,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Azithromycin,00781809031,NDC,250,RC,,,,inpatient,500,ML,0.22,0.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Rifabutin,59762135001A,NDC,250,RC,,,,inpatient,150,ML,12.35,10.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Colistimethate,63323039306A,NDC,250,RC,,,,inpatient,150,ML,14.67,12.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dicyclomine HCl,00527128210A,NDC,250,RC,,,,inpatient,20,ML,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Deep Sea,00904386575,NDC,250,RC,,,,inpatient,1,EA,0.74,0.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Minoxidil,49884025701,NDC,250,RC,,,,inpatient,10,ML,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
clonazePAM,00093083205A,NDC,250,RC,,,,inpatient,0.5,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amicar,49411005030A,NDC,250,RC,,,,inpatient,500,ML,6.11,5.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ketoconazole,51672402601A,NDC,250,RC,,,,inpatient,200,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aztreonam,63323040120B,NDC,250,RC,,,,inpatient,1,GM,21.25,18.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dantrolene Sodium,00527321937,NDC,250,RC,,,,inpatient,25,ML,0.31,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Etoposide,68001026527,NDC,250,RC,,,,inpatient,1000,ML,2.36,2.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Thiothixene,60219167301A,NDC,250,RC,,,,inpatient,1,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00338001704,NDC,250,RC,,,,inpatient,1000,ML,1.42,1.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
medroxyPROGESTERone acetate,59762005601A,NDC,250,RC,,,,inpatient,10,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
DOPamine HCl,00409910420,NDC,250,RC,,,,inpatient,400000,GM,0.61,0.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Exemestane,59762285801A,NDC,250,RC,,,,inpatient,25,ML,5.57,4.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Entresto,00078069620A,NDC,250,RC,,,,inpatient,1,EA,4.59,3.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nicotine Transdermal System,00536589688A,NDC,250,RC,,,,inpatient,21,ML,2.4,2.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calagesic,00395042096,NDC,250,RC,,,,inpatient,1,EA,0.01,0.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Oyster Shell Calcium,00904188361,NDC,250,RC,,,,inpatient,500,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Venlafaxine HCl,68001015900,NDC,250,RC,,,,inpatient,50,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zolpidem Tartrate,13668000801A,NDC,250,RC,,,,inpatient,10,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Heparin Lock Flush,64253033335A,NDC,250,RC,,,,inpatient,5,ML,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nitroglycerin,00517481025,NDC,250,RC,,,,inpatient,50000,GM,8.79,7.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zonisamide,60687023001A,NDC,250,RC,,,,inpatient,100,ML,0.29,0.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aminosyn-RF,00409416603A,NDC,250,RC,,,,inpatient,500,ML,20.56,17.48,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Haloperidol Decanoate,68001058141A,NDC,250,RC,,,,inpatient,100,ML,23.43,19.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
OXcarbazepine,65162064978A,NDC,250,RC,,,,inpatient,300,ML,0.63,0.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Olumiant,00002418230,NDC,250,RC,,,,inpatient,2,ML,78.09,66.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BUPivacaine HCl with EPINEPHrine,00409904217,NDC,250,RC,,,,inpatient,30,ML,2.48,2.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
NovoLIN N (NPH),00169183411A,NDC,250,RC,,,,inpatient,100,UN  ,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Famotidine,63323073912A,NDC,250,RC,,,,inpatient,20,ML,0.66,0.56,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
metroNIDAZOLE,00781707787A,NDC,250,RC,,,,inpatient,1,EA,21.13,17.96,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Torsemide,31722053001,NDC,250,RC,,,,inpatient,10,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fenofibric Acid,59651021790A,NDC,250,RC,,,,inpatient,135,ML,0.26,0.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl,67457082415,NDC,250,RC,,,,inpatient,1500,ML,22.88,19.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ibuprofen,00904585361A,NDC,250,RC,,,,inpatient,400,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cefepime,25021012250B,NDC,250,RC,,,,inpatient,2,GM,5.89,5.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cytarabine,61703030538,NDC,250,RC,,,,inpatient,100,ML,3.34,2.84,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Neo-Synephrine,00225080047B,NDC,250,RC,,,,inpatient,1,EA,20.27,17.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
SEROquel,00310027460,NDC,250,RC,,,,inpatient,300,ML,0.64,0.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
mitoMYcin,16729011638,NDC,250,RC,,,,inpatient,40,ML,129.05,109.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Water For Irrigation,00338000404,NDC,250,RC,,,,inpatient,1000,ML,0.86,0.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
QUEtiapine Fumarate,60687033801A,NDC,250,RC,,,,inpatient,50,ML,0.22,0.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prezcobix,59676057530,NDC,250,RC,,,,inpatient,1,EA,79.76,67.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Norpace CR,00025273231,NDC,250,RC,,,,inpatient,100,ML,1.82,1.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cloNIDine,00591351004A,NDC,250,RC,,,,inpatient,0.3,ML,21.77,18.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Divalproex Sodium,68084031301A,NDC,250,RC,,,,inpatient,125,ML,0.67,0.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
hydrOXYzine Pamoate,00185067601A,NDC,250,RC,,,,inpatient,50,ML,0.31,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PHENobarbital,16571067050A,NDC,250,RC,,,,inpatient,15,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydrocortisone,00168008031,NDC,250,RC,,,,inpatient,1,EA,2.33,1.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Doxycycline,68180065701A,NDC,250,RC,,,,inpatient,25,ML,0.34,0.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Spiriva Respimat Institutional Pack 10ACT,00597010051A,NDC,250,RC,,,,inpatient,1,EA,35.34,30.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexAMETHasone-Neomycin-Polymyxin,61314063136,NDC,250,RC,,,,inpatient,1,EA,9.3,7.91,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Trophamine 10%,00264193310A,NDC,250,RC,,,,inpatient,500,ML,27.61,23.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
EPINEPHrine-lidocaine HCl,00409318101,NDC,250,RC,,,,inpatient,30,ML,5.14,4.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ethambutol HCl,68180028001,NDC,250,RC,,,,inpatient,100,ML,0.34,0.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Promethazine HCl,68084015501,NDC,250,RC,,,,inpatient,25,ML,0.21,0.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00641612625,NDC,250,RC,,,,inpatient,8,ML,0.71,0.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Belsomra,00006003330,NDC,250,RC,,,,inpatient,10,ML,13.04,11.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Erythrocin Lactobionate,00409648201,NDC,250,RC,,,,inpatient,500,ML,72.81,61.89,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Diflucan,00049345019,NDC,250,RC,,,,inpatient,40,ML,0.84,0.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
fentaNYL Citrate-Sodium Chloride,24200025580,NDC,250,RC,,,,inpatient,20,GM,29.98,25.48,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ibuprofen Children's,68094049461A,NDC,250,RC,,,,inpatient,100,ML,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
DULoxetine HCl,60687073401A,NDC,250,RC,,,,inpatient,30,ML,1.17,0.99,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ramipril,68001042900A,NDC,250,RC,,,,inpatient,2.5,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Trihexyphenidyl HCl,69452024120A,NDC,250,RC,,,,inpatient,2,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levalbuterol HCl,66993002127,NDC,250,RC,,,,inpatient,0.31,ML,1.7,1.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PARoxetine HCl,68084004501A,NDC,250,RC,,,,inpatient,20,ML,0.19,0.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Good Neighbor Pharmacy Nicotine Polacrilex,46122017225A,NDC,250,RC,,,,inpatient,4,ML,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
lamiVUDine,60505325106A,NDC,250,RC,,,,inpatient,150,ML,0.63,0.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xylocaine with EPINEPHrine,63323048227,NDC,250,RC,,,,inpatient,20,ML,1.34,1.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Naproxen,68462018901,NDC,250,RC,,,,inpatient,375,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cortifoam,00037683015,NDC,250,RC,,,,inpatient,1,EA,238.19,202.46,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pantoprazole Sodium,51079005120A,NDC,250,RC,,,,inpatient,40,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Repaglinide,65862067101A,NDC,250,RC,,,,inpatient,1,ML,2.27,1.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zinc-220,00731040106A,NDC,250,RC,,,,inpatient,220,ML,0.24,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Anucort-HC,00713050312A,NDC,250,RC,,,,inpatient,25,ML,2.21,1.88,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dilTIAZem HCl,60687019501A,NDC,250,RC,,,,inpatient,120,ML,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cyanocobalamin,00517003125A,NDC,250,RC,,,,inpatient,1000,GM,2.16,1.84,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methadone HCl,00406577162B,NDC,250,RC,,,,inpatient,10,ML,0.34,0.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clinimix E 4.25/5,00338114403,NDC,250,RC,,,,inpatient,1000,ML,12.88,10.95,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Bicarbonate,76329335201A,NDC,250,RC,,,,inpatient,50,UN  ,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gentamicin Sulfate,00338050548,NDC,250,RC,,,,inpatient,100,ML,2.11,1.79,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acyclovir,68084010901A,NDC,250,RC,,,,inpatient,800,ML,0.29,0.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydrocortisone/Neomycin/Polymyxin B,61314064175,NDC,250,RC,,,,inpatient,1,EA,13.2,11.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nicotine Polacrilex,00536136223A,NDC,250,RC,,,,inpatient,2,ML,0.39,0.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hexabrix,00019550508,NDC,250,RC,,,,inpatient,100,ML,98.01,83.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose-Sodium Chloride,00338008503,NDC,250,RC,,,,inpatient,500,ML,0.73,0.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Relistor,65649055102A,NDC,250,RC,,,,inpatient,12,ML,108.85,92.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
glipiZIDE,64980027903A,NDC,250,RC,,,,inpatient,2.5,ML,0.47,0.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pentam,63323011310,NDC,250,RC,,,,inpatient,300,ML,107.27,91.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Phenytoin,60687027566A,NDC,250,RC,,,,inpatient,100,ML,0.87,0.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acyclovir Sodium,63323032520,NDC,250,RC,,,,inpatient,1000,ML,4.39,3.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydrocortisone,68084093025A,NDC,250,RC,,,,inpatient,20,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clotrimazole,00574010777,NDC,250,RC,,,,inpatient,10,ML,1.31,1.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Nitroprusside,71839012001A,NDC,250,RC,,,,inpatient,25000,GM,23.32,19.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
HYDROmorphone HCl,00406324401A,NDC,250,RC,,,,inpatient,4,ML,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Glycopyrrolate,16571074309A,NDC,250,RC,,,,inpatient,1,ML,0.81,0.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Isosorbide Mononitrate,50742017605A,NDC,250,RC,,,,inpatient,60,ML,0.21,0.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Senna,71399823708A,NDC,250,RC,,,,inpatient,8.8,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Albuterol Sulfate,00378705752,NDC,250,RC,,,,inpatient,1,EA,0.46,0.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Atorvastatin Calcium,68084009801A,NDC,250,RC,,,,inpatient,20,ML,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl,63323020320A,NDC,250,RC,,,,inpatient,750,ML,7.19,6.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methyldopa,51079020020,NDC,250,RC,,,,inpatient,250,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
rOPINIRole HCl,68462025701A,NDC,250,RC,,,,inpatient,3,ML,0.2,0.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
OXYTOCIN 15 UNITS in 0.9% NS 250 ML,0270062102420020516B,CDM,250,RC,,,,inpatient,15,UN  ,11,9.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Triamcinolone Acetonide,45802004935,NDC,250,RC,,,,inpatient,1,EA,0.25,0.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nitroglycerin,43598089430A,NDC,250,RC,,,,inpatient,0.4,ML,0.52,0.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Brovana,63402091130,NDC,250,RC,,,,inpatient,1,EA,9.8,8.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Memantine HCl,00904650661A,NDC,250,RC,,,,inpatient,10,ML,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pioglitazone Hydrochloride,00093727298A,NDC,250,RC,,,,inpatient,30,ML,7.39,6.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
OLANZapine,59746030832A,NDC,250,RC,,,,inpatient,10,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Kenalog-40,00003029305,NDC,250,RC,,,,inpatient,40,ML,16.21,13.78,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Naropin,63323028565,NDC,250,RC,,,,inpatient,100,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Kenalog-40,00003029328,NDC,250,RC,,,,inpatient,40,ML,67.37,57.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amidate,00409806201,NDC,250,RC,,,,inpatient,20,ML,10.97,9.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00264751020,NDC,250,RC,,,,inpatient,250,ML,0.84,0.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
CARBOplatin,61703033956A,NDC,250,RC,,,,inpatient,600,ML,45.43,38.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dipyridamole,00641256944,NDC,250,RC,,,,inpatient,50,ML,3.46,2.94,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Carvedilol,00904630061A,NDC,250,RC,,,,inpatient,3.125,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
quiNINE Sulfate,50742023830A,NDC,250,RC,,,,inpatient,324,ML,5.38,4.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Uceris,68012030930,NDC,250,RC,,,,inpatient,9,ML,48.91,41.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00264780010,NDC,250,RC,,,,inpatient,500,ML,3.72,3.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pitocin,42023011625A,NDC,250,RC,,,,inpatient,10,UN  ,5.75,4.89,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tracleer,66215010106,NDC,250,RC,,,,inpatient,62.5,ML,49.5,42.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Rosuvastatin Calcium,27808015601A,NDC,250,RC,,,,inpatient,10,ML,1.03,0.88,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ARIPiprazole,65162089903A,NDC,250,RC,,,,inpatient,15,ML,0.5,0.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dicyclomine HCl,51079011820,NDC,250,RC,,,,inpatient,10,ML,0.42,0.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sevoflurane,10019065164A,NDC,250,RC,,,,inpatient,250,ML,54.09,45.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexAMETHasone Sodium Phosphate,63323050601,NDC,250,RC,,,,inpatient,10,ML,1.27,1.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nystatin,00121086850A,NDC,250,RC,,,,inpatient,500000,UN  ,0.58,0.49,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Entresto,00078065920A,NDC,250,RC,,,,inpatient,1,EA,6.48,5.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xofluza 1X80MG (80MG Dose),50242087701,NDC,250,RC,,,,inpatient,80,ML,150,127.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dapsone,49938010130,NDC,250,RC,,,,inpatient,100,ML,1.08,0.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Naloxone HCl,76329146901,NDC,250,RC,,,,inpatient,1,ML,12.99,11.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tigan,42023011925,NDC,250,RC,,,,inpatient,200,ML,21.76,18.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PHENobarbital Sodium,00641047625,NDC,250,RC,,,,inpatient,65,ML,14.18,12.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levsin,00037900105,NDC,250,RC,,,,inpatient,0.5,ML,25.46,21.64,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Trilipix,00074316190,NDC,250,RC,,,,inpatient,45,ML,1.45,1.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methadone HCl,67457021720,NDC,250,RC,,,,inpatient,10,ML,9.97,8.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Water For Injection,00517305025,NDC,250,RC,,,,inpatient,50,ML,2.6,2.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zidovudine,65862002460A,NDC,250,RC,,,,inpatient,300,ML,0.21,0.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Viibryd,00456111030,NDC,250,RC,,,,inpatient,10,ML,4.88,4.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Betamethasone Dipropionate,45802002146A,NDC,250,RC,,,,inpatient,1,EA,31.74,26.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Multaq,00024414260,NDC,250,RC,,,,inpatient,400,ML,10.2,8.67,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tarceva,50242006301,NDC,250,RC,,,,inpatient,100,ML,126.37,107.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
EPINEPHrine HCl,00409490118,NDC,250,RC,,,,inpatient,1,ML,7,5.95,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Enalapril Maleate,43547054710A,NDC,250,RC,,,,inpatient,10,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Atenolol,51079075920A,NDC,250,RC,,,,inpatient,25,ML,0.16,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine-Prilocaine,00574204230A,NDC,250,RC,,,,inpatient,1,EA,7.11,6.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Empty Evacuated Container,00074161405,NDC,250,RC,,,,inpatient,1,UN  ,9.47,8.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Venlafaxine HCl,51079048201A,NDC,250,RC,,,,inpatient,75,ML,0.26,0.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Verapamil HCl,00591040401,NDC,250,RC,,,,inpatient,40,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cloNIDine HCl,68001023700A,NDC,250,RC,,,,inpatient,0.1,ML,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00338001702,NDC,250,RC,,,,inpatient,1,EA,0.64,0.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Stratuscare,58980040912A,NDC,250,RC,,,,inpatient,1,EA,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lyrica,00071101441A,NDC,250,RC,,,,inpatient,75,ML,7.33,6.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
glyBURIDE,72241004005A,NDC,250,RC,,,,inpatient,5,ML,0.38,0.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
predniSONE,00054874025,NDC,250,RC,,,,inpatient,2.5,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Folic Acid,63323018410,NDC,250,RC,,,,inpatient,5,ML,4.28,3.64,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clindamycin,00781329009A,NDC,250,RC,,,,inpatient,900,ML,14.07,11.96,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
metFORMIN HCl,60687014301A,NDC,250,RC,,,,inpatient,850,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
carBAMazepine,51079087020,NDC,250,RC,,,,inpatient,100,ML,0.43,0.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Flurbiprofen Sodium,69292072225A,NDC,250,RC,,,,inpatient,1,EA,52.86,44.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
SSKI,71740011230A,NDC,250,RC,,,,inpatient,30,ML,0.17,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Doxazosin Mesylate,68084083625A,NDC,250,RC,,,,inpatient,1,ML,0.49,0.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mestinon,00187301220,NDC,250,RC,,,,inpatient,60,ML,2.35,2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Venlafaxine HCl,00093914701,NDC,250,RC,,,,inpatient,25,ML,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Phenazopyridine HCl,51293081001A,NDC,250,RC,,,,inpatient,100,ML,0.92,0.78,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
First-Mouthwash BLM,65628005004,NDC,250,RC,,,,inpatient,240,ML,17.95,15.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
TetraVisc,54799050501,NDC,250,RC,,,,inpatient,1,EA,6.53,5.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
buPROPion HCl XL,63304072390A,NDC,250,RC,,,,inpatient,150,ML,3.75,3.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Neo-Synephrine,00225080047A,NDC,250,RC,,,,inpatient,1,EA,0.24,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
NovoLOG,00169750111B,NDC,250,RC,,,,inpatient,100,UN  ,0.82,0.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
FeverAll Jr. Strength,51672211602A,NDC,250,RC,,,,inpatient,325,ML,0.46,0.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
fentaNYL Citrate,00641602510,NDC,250,RC,,,,inpatient,250,GM,3.44,2.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Linezolid,67877041920A,NDC,250,RC,,,,inpatient,600,ML,0.61,0.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aquanil Hc,00096073204A,NDC,250,RC,,,,inpatient,1,EA,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Neo-Synephrine,00225080547A,NDC,250,RC,,,,inpatient,1,EA,0.24,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Chloroquine Phosphate,64980017802A,NDC,250,RC,,,,inpatient,500,ML,6.33,5.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xerava,71773005012,NDC,250,RC,,,,inpatient,50,ML,57,48.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Venofer,00517231005,NDC,250,RC,,,,inpatient,200,ML,51.83,44.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
LIDOCAINE 4% PATCH,0270114671399388406A,CDM,250,RC,,,,inpatient,1,UN  ,5.85,4.97,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Trumenba,00005010005,NDC,250,RC,,,,inpatient,120,GM,150.78,128.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Remifentanil Hydrochloride,00143939110,NDC,250,RC,,,,inpatient,1,ML,43.37,36.86,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Propranolol HCl,00527411737A,NDC,250,RC,,,,inpatient,80,ML,0.52,0.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clindamycin HCl,68084024401,NDC,250,RC,,,,inpatient,300,ML,0.65,0.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
sulfADIAZINE,42806075760A,NDC,250,RC,,,,inpatient,500,ML,2.09,1.78,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Potassium Chloride,00409665305,NDC,250,RC,,,,inpatient,40,UN  ,1.28,1.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cerebyx,00069600125A,NDC,250,RC,,,,inpatient,100,ML,7.46,6.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cyproheptadine HCl,70752010112A,NDC,250,RC,,,,inpatient,2,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Isentress,00006022761,NDC,250,RC,,,,inpatient,400,ML,32.28,27.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Loratadine,68084024801A,NDC,250,RC,,,,inpatient,10,ML,0.2,0.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
vinBLAStine Sulfate,63323027810,NDC,250,RC,,,,inpatient,1,ML,1.97,1.67,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
hydrALAZINE HCl,31722052101A,NDC,250,RC,,,,inpatient,50,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Labetalol HCl,51079092820A,NDC,250,RC,,,,inpatient,100,ML,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lacri-Lube S.O.P.,00023031207,NDC,250,RC,,,,inpatient,1,EA,1.91,1.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluconazole,55390019401A,NDC,250,RC,,,,inpatient,100,ML,6.11,5.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Children's Fever Reducer,45802073233A,NDC,250,RC,,,,inpatient,120,ML,0.43,0.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluorouracil,51672406201,NDC,250,RC,,,,inpatient,1,EA,48.41,41.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methotrexate Sodium,63323012250,NDC,250,RC,,,,inpatient,1000,ML,57.67,49.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dicloxacillin Sodium,00093312301,NDC,250,RC,,,,inpatient,250,ML,0.46,0.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Victoza Pen,00169406012,NDC,250,RC,,,,inpatient,0.6,ML,260.29,221.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cortenema,62559011107A,NDC,250,RC,,,,inpatient,100,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PACLitaxel,70860020005A,NDC,250,RC,,,,inpatient,30,ML,53.24,45.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lexiscan,00469650189,NDC,250,RC,,,,inpatient,0.4,ML,170.38,144.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Infanrix,58160081011,NDC,250,RC,,,,inpatient,0.5,ML,20.29,17.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
LORazepam,51079038620,NDC,250,RC,,,,inpatient,1,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
chlordiazePOXIDE HCl,00555015802A,NDC,250,RC,,,,inpatient,5,ML,0.51,0.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mesalamine,45802009828A,NDC,250,RC,,,,inpatient,4,GM,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ibuprofen,67877032001A,NDC,250,RC,,,,inpatient,600,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Labetalol HCl,00409226754,NDC,250,RC,,,,inpatient,5,ML,3.13,2.66,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aspirin Micro-Coated,66553000101A,NDC,250,RC,,,,inpatient,325,ML,0.25,0.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Naproxen,60687049101A,NDC,250,RC,,,,inpatient,500,ML,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Megestrol Acetate,66689002001A,NDC,250,RC,,,,inpatient,40,ML,1.15,0.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Topiramate,68084034201A,NDC,250,RC,,,,inpatient,25,ML,0.35,0.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xylocaine,63323048527,NDC,250,RC,,,,inpatient,10,ML,0.88,0.75,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydrocortisone,45802093716,NDC,250,RC,,,,inpatient,1,EA,0.36,0.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
oseltamivir phosphate,70710116506A,NDC,250,RC,,,,inpatient,6,ML,0.6,0.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cilostazol,00093206506A,NDC,250,RC,,,,inpatient,50,ML,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cefepime,25021012120A,NDC,250,RC,,,,inpatient,1,GM,2.73,2.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Simplist Dilaudid,76045000905,NDC,250,RC,,,,inpatient,0.5,ML,3.19,2.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00409713202,NDC,250,RC,,,,inpatient,250,ML,2.18,1.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Finasteride,60687042801A,NDC,250,RC,,,,inpatient,5,ML,2.23,1.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
DULoxetine HCl,51991074890A,NDC,250,RC,,,,inpatient,60,ML,4.96,4.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tropicamide,70069012101A,NDC,250,RC,,,,inpatient,1,EA,4.73,4.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Verapamil HCl,75834015901A,NDC,250,RC,,,,inpatient,240,ML,1.84,1.56,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Temozolomide,16729004954A,NDC,250,RC,,,,inpatient,20,ML,36.34,30.89,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ziprasidone HCl,68084010509A,NDC,250,RC,,,,inpatient,60,ML,13.33,11.33,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cyclogyl,00065039705A,NDC,250,RC,,,,inpatient,1,EA,3.79,3.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Empty Evacuated Container,00074161402,NDC,250,RC,,,,inpatient,1,UN  ,16.64,14.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Propranolol HCl,00143987201A,NDC,250,RC,,,,inpatient,1,ML,1.35,1.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Benztropine Mesylate,68084038801A,NDC,250,RC,,,,inpatient,1,ML,0.31,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Azithromycin,51224022230A,NDC,250,RC,,,,inpatient,600,ML,3.54,3.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl (Premix),70594004301,NDC,250,RC,,,,inpatient,1500,ML,18.5,15.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Valsartan,55111073290A,NDC,250,RC,,,,inpatient,80,ML,0.36,0.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Temazepam,51079041820,NDC,250,RC,,,,inpatient,15,ML,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cefTRIAXone/Dextrose,00264315511,NDC,250,RC,,,,inpatient,2,GM,17.62,14.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Warfarin Sodium,65162076410A,NDC,250,RC,,,,inpatient,3,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
EpiPen Jr Auto-Injector,49502050101A,NDC,250,RC,,,,inpatient,0.15,ML,80.59,68.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine-Prilocaine,00168035755A,NDC,250,RC,,,,inpatient,1,EA,5.17,4.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aminocaproic Acid,00409434673,NDC,250,RC,,,,inpatient,5,GM,0.68,0.58,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ketorolac Tromethamine,00409379501A,NDC,250,RC,,,,inpatient,30,ML,2.07,1.76,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dilTIAZem HCl,60687021701A,NDC,250,RC,,,,inpatient,240,ML,0.7,0.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
valGANciclovir hydrochloride,68084096525A,NDC,250,RC,,,,inpatient,450,ML,82.21,69.88,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Diclofenac Sodium,16571020310,NDC,250,RC,,,,inpatient,25,ML,1.04,0.88,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Demerol Hydrochloride,00409118069,NDC,250,RC,,,,inpatient,100,ML,1.3,1.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Viibryd,00456114030,NDC,250,RC,,,,inpatient,40,ML,4.11,3.49,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Terbutaline Sulfate,00143974610,NDC,250,RC,,,,inpatient,1,ML,1.31,1.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Norpace CR,00025274231,NDC,250,RC,,,,inpatient,150,ML,2.59,2.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00264780020,NDC,250,RC,,,,inpatient,250,ML,1.25,1.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Digoxin,00904592161A,NDC,250,RC,,,,inpatient,0.125,ML,0.73,0.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
LORazepam,00409198530,NDC,250,RC,,,,inpatient,2,ML,3.16,2.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
diazePAM,51079028420,NDC,250,RC,,,,inpatient,2,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Niferex-150 Forte,64011016426,NDC,250,RC,,,,inpatient,1,EA,1,0.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin C,54629006901,NDC,250,RC,,,,inpatient,250,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Epivir,49702020413,NDC,250,RC,,,,inpatient,300,ML,11.19,9.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Polymyxin B/Trimethoprim Sulfate,61314062810B,NDC,250,RC,,,,inpatient,1,EA,4.33,3.68,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Moexipril Hydrochloride,68462020901A,NDC,250,RC,,,,inpatient,7.5,ML,2.01,1.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexAMETHasone,00054818325,NDC,250,RC,,,,inpatient,6,ML,1.44,1.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
guaiFENesin,00121174410,NDC,250,RC,,,,inpatient,10,ML,0.48,0.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00406831562A,NDC,250,RC,,,,inpatient,15,ML,1.05,0.89,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00641606801,NDC,250,RC,,,,inpatient,100,ML,6.25,5.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cefOXitin Sodium,60505075905,NDC,250,RC,,,,inpatient,1,GM,2.84,2.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00409488803,NDC,250,RC,,,,inpatient,20,ML,1.55,1.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levophed,00409337504,NDC,250,RC,,,,inpatient,1000,GM,1.19,1.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bisacodyl,00574705012A,NDC,250,RC,,,,inpatient,10,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fludrocortisone Acetate AvPak,50268033015A,NDC,250,RC,,,,inpatient,0.1,ML,0.4,0.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Miacalcin,67457067502,NDC,250,RC,,,,inpatient,400,UN  ,762.95,648.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
fentaNYL Citrate,63323080605A,NDC,250,RC,,,,inpatient,500,GM,10,8.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PACLitaxel,00703321801A,NDC,250,RC,,,,inpatient,300,ML,0.7,0.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Isosorbide Mononitrate,50742017505A,NDC,250,RC,,,,inpatient,30,ML,0.22,0.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tetanus Toxoid Adsorbed,49281082010,NDC,636,RC,,,,outpatient,0.5,ML,30.27,25.73,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,3783,,facility
Albumin Human,68982062302A,NDC,250,RC,,,,inpatient,12.5,GM,44.63,37.94,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Procainamide HCl,14789090002A,NDC,250,RC,,,,inpatient,1000,ML,52.59,44.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl-Dextrose,00409471201,NDC,250,RC,,,,inpatient,2,ML,5.67,4.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Menveo,58160095509,NDC,250,RC,,,,inpatient,0.5,ML,89.42,76.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
EPINEPHrine-lidocaine HCl,00409317803B,NDC,250,RC,,,,inpatient,50,ML,2.15,1.83,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sulfamethoxazole/Trimethoprim DS,72789001860A,NDC,250,RC,,,,inpatient,1,EA,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Isosorbide Mononitrate,00228262011B,NDC,250,RC,,,,inpatient,20,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
lamoTRIgine,62332003731A,NDC,250,RC,,,,inpatient,25,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amikacin Sulfate,23155029042A,NDC,250,RC,,,,inpatient,1000,ML,9.67,8.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Glucagen,00597005345A,NDC,250,RC,,,,inpatient,1,ML,208.86,177.53,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
diazePAM,51079028520,NDC,250,RC,,,,inpatient,5,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Voriconazole,68462057230,NDC,250,RC,,,,inpatient,50,ML,4.26,3.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
fentaNYL Citrate,00641624725,NDC,250,RC,,,,inpatient,50,GM,1.29,1.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xarelto,50458057760A,NDC,250,RC,,,,inpatient,2.5,ML,5.57,4.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Enalapril Maleate,00904560961A,NDC,250,RC,,,,inpatient,2.5,ML,0.4,0.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Labetalol HCl,36000032010,NDC,250,RC,,,,inpatient,20,ML,3.21,2.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tropicamide,61314035401,NDC,250,RC,,,,inpatient,1,EA,5.1,4.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Terbutaline Sulfate,00527131801A,NDC,250,RC,,,,inpatient,2.5,ML,0.6,0.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Quinapril,62135048690A,NDC,250,RC,,,,inpatient,20,ML,0.94,0.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cefpodoxime Proxetil,00781543820,NDC,250,RC,,,,inpatient,100,ML,4.19,3.56,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Precedex,00409163802,NDC,250,RC,,,,inpatient,200,GM,1.79,1.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ferrex 150,00904539561,NDC,250,RC,,,,inpatient,150,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluorouracil,51672406301,NDC,250,RC,,,,inpatient,1,EA,76.13,64.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
MIDAZOLAM IN NS 100 MG/100 ML BAG (,0270073670092103036,CDM,250,RC,,,,inpatient,1,ML,0.25,0.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dilTIAZem HCl,68682000750A,NDC,250,RC,,,,inpatient,60,ML,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Metoclopramide HCl,00409341401A,NDC,250,RC,,,,inpatient,5,ML,1.85,1.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Chlorthalidone,51079005820A,NDC,250,RC,,,,inpatient,25,ML,1.67,1.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methadone HCl,00406577162A,NDC,250,RC,,,,inpatient,10,ML,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nitrostat,00071041724,NDC,250,RC,,,,inpatient,0.3,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Anbesol,00573021825A,NDC,250,RC,,,,inpatient,1,EA,3.56,3.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,00409427702,NDC,250,RC,,,,inpatient,20,ML,2.2,1.87,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
sulfaSALAzine,00093323401A,NDC,250,RC,,,,inpatient,500,ML,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ketamine HCl,00409205105,NDC,250,RC,,,,inpatient,100,ML,6.36,5.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
medroxyPROGESTERone acetate,59762005501A,NDC,250,RC,,,,inpatient,2.5,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Eliquis,00003089431A,NDC,250,RC,,,,inpatient,5,ML,2.36,2.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Accupril,00071053023A,NDC,250,RC,,,,inpatient,10,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ganciclovir,63323031510A,NDC,250,RC,,,,inpatient,500,ML,94.13,80.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cefOXitin Sodium,25021011020A,NDC,250,RC,,,,inpatient,2,GM,7.57,6.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Chlorhexidine Gluconate,00116200104,NDC,250,RC,,,,inpatient,1,ML,1.08,0.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
diazePAM,68682065020A,NDC,250,RC,,,,inpatient,2.5,ML,127.37,108.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Loperamide HCl,50383061804A,NDC,250,RC,,,,inpatient,1,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Heparin Sodium,63323027602,NDC,250,RC,,,,inpatient,2000,UN  ,0.81,0.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Bicarbonate,00409490034,NDC,250,RC,,,,inpatient,10,UN  ,10.13,8.61,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
FLUoxetine HCl,63629219701A,NDC,250,RC,,,,inpatient,10,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Venlafaxine HCl,00093916301,NDC,250,RC,,,,inpatient,100,ML,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Meropenem,63323050830A,NDC,250,RC,,,,inpatient,1,GM,4.21,3.58,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Protonix,00008084402,NDC,250,RC,,,,inpatient,40,ML,11.42,9.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin A,00904208560,NDC,250,RC,,,,inpatient,10000,UN  ,0.22,0.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ketalar,42023011310A,NDC,250,RC,,,,inpatient,200,ML,9.28,7.89,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tamsulosin HCl,68084029901A,NDC,250,RC,,,,inpatient,0.4,ML,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
RisperDAL Consta,50458030611,NDC,250,RC,,,,inpatient,25,ML,274.21,233.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lactated Ringer's,00338011704,NDC,250,RC,,,,inpatient,1000,ML,0.94,0.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Bicarbonate,00223172001,NDC,250,RC,,,,inpatient,325,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
oxyCODONE HCl,68084035401A,NDC,250,RC,,,,inpatient,5,ML,0.27,0.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pedialyte Singles,70074056442A,NDC,250,RC,,,,inpatient,118,ML,1.38,1.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Midazolam HCl,00409259605D,NDC,250,RC,,,,inpatient,100,ML,110.21,93.68,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Samsca,59148002150,NDC,250,RC,,,,inpatient,30,ML,305.31,259.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Miconazole 7,61269073607A,NDC,250,RC,,,,inpatient,100,ML,0.41,0.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Indigo Carmine,00517037510,NDC,250,RC,,,,inpatient,5,ML,3.65,3.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vigamox,00078093926,NDC,250,RC,,,,inpatient,1,EA,18.69,15.89,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
clomiPRAMINE HCl,68084081825,NDC,250,RC,,,,inpatient,50,ML,11.29,9.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gentamicin Sulfate,63323001002,NDC,250,RC,,,,inpatient,80,ML,1.24,1.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Benzoin Compound,00395024392B,NDC,250,RC,,,,inpatient,1,EA,2.87,2.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bethanechol Chloride,00832051100A,NDC,250,RC,,,,inpatient,10,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fosamprenavir Calcium,00378352091A,NDC,250,RC,,,,inpatient,700,ML,15.29,13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Atovaquone/Proguanil HCl,68001024515,NDC,250,RC,,,,inpatient,1,EA,4.72,4.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Theophylline,54838055680,NDC,250,RC,,,,inpatient,80,ML,2.72,2.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
morphine SULFATE/PF 1 MG/2 ML (2cc,0270073970092113243,CDM,250,RC,,,,inpatient,1,ML,4.46,3.79,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Benzoin Tincture,40565011182A,NDC,250,RC,,,,inpatient,1,EA,20.13,17.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
traZODone hydrochloride,60687044301A,NDC,250,RC,,,,inpatient,50,ML,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Divalproex Sodium,51079076608A,NDC,250,RC,,,,inpatient,250,ML,0.71,0.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cyclobenzaprine HCl,68084075325,NDC,250,RC,,,,inpatient,5,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
carBAMazepine,00121189494A,NDC,250,RC,,,,inpatient,200,ML,3.22,2.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Phentolamine Mesylate,68094010120A,NDC,250,RC,,,,inpatient,5,ML,117.24,99.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Edecrin,25010021515A,NDC,250,RC,,,,inpatient,25,ML,6.15,5.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexAMETHasone Sodium Phosphate,63323016501,NDC,250,RC,,,,inpatient,4,ML,0.67,0.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Doxy 100,63323013011,NDC,250,RC,,,,inpatient,100,ML,12.5,10.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
FLUoxetine HCl,65862019399A,NDC,250,RC,,,,inpatient,20,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Abacavir,68084002121A,NDC,250,RC,,,,inpatient,300,ML,2.21,1.88,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Naropin,63323028520,NDC,250,RC,,,,inpatient,2,ML,0.26,0.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Flumazenil,00143978410A,NDC,250,RC,,,,inpatient,0.5,ML,9.42,8.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose-Sodium Chloride,00264761410,NDC,250,RC,,,,inpatient,500,ML,5,4.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cortisone Acetate,62135017330A,NDC,250,RC,,,,inpatient,25,ML,2.44,2.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Benztropine Mesylate,69097083207A,NDC,250,RC,,,,inpatient,2,ML,1.67,1.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,63807010030,NDC,250,RC,,,,inpatient,2.5,ML,0.32,0.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pilocarpine HCl,61314020315,NDC,250,RC,,,,inpatient,1,EA,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00406800315A,NDC,250,RC,,,,inpatient,20,ML,13.86,11.78,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Leucovorin Calcium,25021081530,NDC,250,RC,,,,inpatient,200,ML,18.99,16.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Curosurf,10122051003,NDC,250,RC,,,,inpatient,240,ML,731.1,621.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
chlordiazePOXIDE HCl,00555015902A,NDC,250,RC,,,,inpatient,25,ML,0.5,0.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
traZODone hydrochloride,60687045401B,NDC,250,RC,,,,inpatient,100,ML,0.24,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cloZAPine,51079092220,NDC,250,RC,,,,inpatient,100,ML,1.48,1.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Loperamide HCl,51079069020,NDC,250,RC,,,,inpatient,2,ML,0.61,0.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lithium Carbonate,00054852725,NDC,250,RC,,,,inpatient,300,ML,0.16,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gemcitabine,71288011728A,NDC,250,RC,,,,inpatient,1,GM,14.71,12.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ferrous Sulfate,00574060811,NDC,250,RC,,,,inpatient,325,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydrocortisone,51672201002A,NDC,250,RC,,,,inpatient,1,EA,1.93,1.64,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BUPivacaine HCl,00409116201,NDC,250,RC,,,,inpatient,50,ML,1.08,0.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
HYDROmorphone HCl,00409255201A,NDC,250,RC,,,,inpatient,1,ML,1,0.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
"cycloSPORINE, modified",23155083830A,NDC,250,RC,,,,inpatient,50,ML,0.61,0.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
OXYTOCIN 30 UNITS in 0.9% NS 500 ML,0270059602420020516A,CDM,250,RC,,,,inpatient,30,UN  ,15,12.75,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cycloPHOSphamide,54879002101,NDC,250,RC,,,,inpatient,25,ML,5.22,4.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
EPINEPHrine-lidocaine HCl,00409317701,NDC,250,RC,,,,inpatient,50,ML,2.47,2.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00338001741A,NDC,250,RC,,,,inpatient,50,ML,2.85,2.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Heparin Sodium-Sodium Chloride,63323051877A,NDC,250,RC,,,,inpatient,25000,UN  ,5.73,4.87,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
NIFEdipine,50742062001A,NDC,250,RC,,,,inpatient,30,ML,0.81,0.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ATROPINE SO4 0.4 MG/1 ML VIAL,0260418900641625110A,CDM,250,RC,,,,inpatient,0.4,ML,0.63,0.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methylphenidate HCl,57664022888A,NDC,250,RC,,,,inpatient,5,ML,0.38,0.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levothyroxine Sodium,00378181177,NDC,250,RC,,,,inpatient,112,GM,0.32,0.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Entereg,67919002010A,NDC,250,RC,,,,inpatient,12,ML,132.63,112.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Promethazine HCl,45802075930A,NDC,250,RC,,,,inpatient,25,ML,8.19,6.96,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ALPRAZolam,65862067905A,NDC,250,RC,,,,inpatient,2,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Furosemide,51079007320,NDC,250,RC,,,,inpatient,40,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
hydrALAZINE HCl,68084044701A,NDC,250,RC,,,,inpatient,10,ML,1,0.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ceFAZolin Sodium,00143992390,NDC,250,RC,,,,inpatient,500,ML,0.89,0.76,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00338005403,NDC,250,RC,,,,inpatient,500,ML,0.71,0.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Elitek,00024515175,NDC,250,RC,,,,inpatient,7.5,ML,3777,3210.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
NP Thyroid 15,42192032701,NDC,250,RC,,,,inpatient,15,ML,0.36,0.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lisinopril,00591040801A,NDC,250,RC,,,,inpatient,20,ML,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ipratropium Bromide-Albuterol Sulfate,00487020103A,NDC,250,RC,,,,inpatient,1,EA,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nitroglycerin Transdermal System,00378911693A,NDC,250,RC,,,,inpatient,0.6,ML,0.84,0.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
niCARdipine HCl,00143968901,NDC,250,RC,,,,inpatient,25,ML,15.53,13.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
amLODIPine Besylate,60687048801A,NDC,250,RC,,,,inpatient,5,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Isosorbide Dinitrate,00781163501C,NDC,250,RC,,,,inpatient,5,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nplate,55513022101,NDC,250,RC,,,,inpatient,250,GM,971.13,825.46,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cytra-K,60258000316,NDC,250,RC,,,,inpatient,2,UN  ,1.28,1.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Azithromycin,59762219803A,NDC,250,RC,,,,inpatient,250,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
VIAFLEX 250ML 1 EACH,0269999650085412096,CDM,250,RC,,,,inpatient,1,EA,3.54,3.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dakin's Solution Half Strength,00436093616,NDC,250,RC,,,,inpatient,1,EA,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Enalaprilat,00143978610,NDC,250,RC,,,,inpatient,2.5,ML,1.85,1.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Valproate Sodium,00143978510A,NDC,250,RC,,,,inpatient,500,ML,7.06,6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
FML S.O.P.,00023031604,NDC,250,RC,,,,inpatient,1,EA,144.9,123.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nebupent,63323087715A,NDC,250,RC,,,,inpatient,300,ML,98.74,83.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bacitracin,00574402235,NDC,250,RC,,,,inpatient,1,EA,56.46,47.99,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Warfarin Sodium,65162076611A,NDC,250,RC,,,,inpatient,5,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Magnesium Oxide,54738097312B,NDC,250,RC,,,,inpatient,400,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Multitrace-4 Concentrated,00517721025,NDC,250,RC,,,,inpatient,1,ML,0.76,0.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose,00409664802,NDC,250,RC,,,,inpatient,25,GM,0.97,0.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Metoprolol Succinate,68001035600A,NDC,250,RC,,,,inpatient,25,ML,0.56,0.48,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tivicay,49702022813,NDC,250,RC,,,,inpatient,50,ML,72.99,62.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Donepezil HCl,00904647861A,NDC,250,RC,,,,inpatient,10,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cefepime,25021012250A,NDC,250,RC,,,,inpatient,2,GM,4.46,3.79,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexAMETHasone Sodium Phosphate,63323051610,NDC,250,RC,,,,inpatient,100,ML,10.26,8.72,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
QUEtiapine Fumarate,68001060106A,NDC,250,RC,,,,inpatient,300,ML,11.42,9.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Saphris,00456240560A,NDC,250,RC,,,,inpatient,5,ML,8.26,7.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Armour Thyroid,52959014900A,NDC,250,RC,,,,inpatient,60,ML,0.29,0.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
risperiDONE,68084027001,NDC,250,RC,,,,inpatient,0.25,ML,0.19,0.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sterile Water,00990797305A,NDC,250,RC,,,,inpatient,1500,ML,1.3,1.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xarelto,50458057910A,NDC,250,RC,,,,inpatient,20,ML,11.14,9.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Suboxone,12496120803,NDC,250,RC,,,,inpatient,1,EA,8.12,6.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin B1,77333093410A,NDC,250,RC,,,,inpatient,100,ML,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Bicarbonate,00409553414A,NDC,250,RC,,,,inpatient,0.5,UN  ,0.36,0.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cephalexin,00093417773,NDC,250,RC,,,,inpatient,250,ML,0.26,0.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pepto-Bismol,37000047516A,NDC,250,RC,,,,inpatient,30,ML,0.19,0.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Unasyn,00049001483A,NDC,250,RC,,,,inpatient,3,GM,3.65,3.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Rifadin IV,00068059701A,NDC,250,RC,,,,inpatient,600,ML,53.87,45.79,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Phenytoin Sodium,00641255545,NDC,250,RC,,,,inpatient,250,ML,1.37,1.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluconazole in Sodium Chloride,69784000306A,NDC,250,RC,,,,inpatient,400,ML,1.1,0.94,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Potassium Phosphate,00409729501A,NDC,250,RC,,,,inpatient,45,EA,14.13,12.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bacitracin/Neomycin/Polymyxin,24208078055,NDC,250,RC,,,,inpatient,1,EA,13.2,11.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mydriacyl,00998035515,NDC,250,RC,,,,inpatient,1,EA,4.73,4.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Caldolor,66220028708,NDC,250,RC,,,,inpatient,800,ML,2.79,2.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ranolazine,27241012502A,NDC,250,RC,,,,inpatient,500,ML,0.25,0.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
atomoxetine hydrochloride,55111052230,NDC,250,RC,,,,inpatient,60,ML,1.22,1.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetic Acid/Hc,51672300701A,NDC,250,RC,,,,inpatient,1,EA,73.27,62.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetylcysteine,63323069210A,NDC,250,RC,,,,inpatient,2000,ML,0.71,0.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Timolol Maleate,62332054505,NDC,250,RC,,,,inpatient,1,EA,142.67,121.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clindamycin Phosphate-Sodium Chloride,00338954924,NDC,250,RC,,,,inpatient,600,ML,100.82,85.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Jardiance,00597015337,NDC,250,RC,,,,inpatient,25,ML,12.32,10.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
New-Skin,16864045001,NDC,250,RC,,,,inpatient,1,EA,3.5,2.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl,62559083080B,NDC,250,RC,,,,inpatient,125,ML,2,1.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Relistor,65649055204,NDC,250,RC,,,,inpatient,8,ML,151.06,128.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Rexulti,59148003713,NDC,250,RC,,,,inpatient,1,ML,46.22,39.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
FeverAll Infants',51672211402,NDC,250,RC,,,,inpatient,80,ML,0.62,0.53,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Midazolam HCl,60687057610,NDC,250,RC,,,,inpatient,5,ML,4.28,3.64,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tobramycin,47335017149,NDC,250,RC,,,,inpatient,300,ML,8.83,7.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
clonazePAM,49884030902,NDC,250,RC,,,,inpatient,1,ML,0.46,0.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Famotidine,68180015001A,NDC,250,RC,,,,inpatient,20,ML,2,1.7,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
DOCEtaxel,16729026765,NDC,250,RC,,,,inpatient,160,ML,25.19,21.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Valsartan,55111073130A,NDC,250,RC,,,,inpatient,40,ML,6.38,5.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Chlorhexidine Gluconate,69339013817A,NDC,250,RC,,,,inpatient,15,ML,1.52,1.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
metOLazone,51079002420A,NDC,250,RC,,,,inpatient,5,ML,1.25,1.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cefTRIAXone/Dextrose,00264315311,NDC,250,RC,,,,inpatient,1,GM,11.1,9.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ibuprofen,45802095243,NDC,250,RC,,,,inpatient,100,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Spray Extension Tube,00283118520,NDC,250,RC,,,,inpatient,1,EA,13.18,11.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
levoFLOXacin,17478010720A,NDC,250,RC,,,,inpatient,25,ML,0.65,0.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Truvada,61958070101,NDC,250,RC,,,,inpatient,1,EA,2.3,1.96,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sulfamethoxazole/Trimethoprim,65862041901A,NDC,250,RC,,,,inpatient,1,EA,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Isosorbide Mononitrate,00228263111A,NDC,250,RC,,,,inpatient,10,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00054023755B,NDC,250,RC,,,,inpatient,0.1,ML,0.5,0.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose/NaCl/Potassium Chloride,00338067304,NDC,250,RC,,,,inpatient,30,UN  ,1.21,1.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
predniSONE,59746017106A,NDC,250,RC,,,,inpatient,1,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
buPROPion HCl,23155019201A,NDC,250,RC,,,,inpatient,100,ML,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
ceFAZolin in Dextrose,00338350341,NDC,250,RC,,,,inpatient,1,GM,5.6,4.76,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Haloperidol,51079073320,NDC,250,RC,,,,inpatient,0.5,ML,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pradaxa,00597036082A,NDC,250,RC,,,,inpatient,150,ML,5.65,4.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Carbidopa/Levodopa/Entacapone,00781561301A,NDC,250,RC,,,,inpatient,1,EA,3.09,2.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Varenicline,49884015576A,NDC,250,RC,,,,inpatient,0.5,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Triamcinolone Acetonide,00168000380,NDC,250,RC,,,,inpatient,1,EA,6.88,5.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ampicillin,25021013610A,NDC,250,RC,,,,inpatient,1,GM,1.65,1.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Flecainide Acetate,00054001020A,NDC,250,RC,,,,inpatient,50,ML,0.52,0.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Triamcinolone Acetonide,45802005536A,NDC,250,RC,,,,inpatient,1,EA,11.03,9.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Heparin Lock Flush,64253033335C,NDC,250,RC,,,,inpatient,10,ML,1,0.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acyclovir,50383081016A,NDC,250,RC,,,,inpatient,200,ML,0.21,0.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Bicarbonate,66553000801,NDC,250,RC,,,,inpatient,650,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Milk Of Magnesia,00121043130A,NDC,250,RC,,,,inpatient,30,ML,0.92,0.78,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Potassium Chloride,14789010816A,NDC,250,RC,,,,inpatient,20,UN  ,2.68,2.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00338004803,NDC,250,RC,,,,inpatient,500,ML,2.34,1.99,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mastisol,00496052348,NDC,250,RC,,,,inpatient,1,ML,2.01,1.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ampicillin Sodium,65219002023A,NDC,250,RC,,,,inpatient,2,GM,3.29,2.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Temozolomide,16729004854A,NDC,250,RC,,,,inpatient,5,ML,9.13,7.76,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose-Sodium Chloride,00338008904,NDC,250,RC,,,,inpatient,1000,ML,1.91,1.62,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Atropine Sulfate,00409491134,NDC,250,RC,,,,inpatient,1,ML,8.38,7.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Valproic Acid,00121467540A,NDC,250,RC,,,,inpatient,250,ML,1.08,0.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Citalopram,00904608461A,NDC,250,RC,,,,inpatient,10,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clinimix 8/14,00338018404,NDC,250,RC,,,,inpatient,2000,ML,67.64,57.49,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Midodrine HCl,00245021211A,NDC,250,RC,,,,inpatient,5,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
clonazePAM,49884030702,NDC,250,RC,,,,inpatient,0.25,ML,0.51,0.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ferrous Sulfate,52959086208,NDC,250,RC,,,,inpatient,220,ML,0.25,0.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Warfarin Sodium,65162076110A,NDC,250,RC,,,,inpatient,1,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride Concentrate,63323009330A,NDC,250,RC,,,,inpatient,120,UN  ,2.69,2.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Water For Injection,00409488799,NDC,250,RC,,,,inpatient,100,ML,4.48,3.81,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
EPINEPHrine-lidocaine HCl,00409318301,NDC,250,RC,,,,inpatient,20,ML,0.57,0.48,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Phosphate,00517341525,NDC,250,RC,,,,inpatient,45,EA,20.15,17.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lactated Ringer's and 5% Dextrose,00338012504,NDC,250,RC,,,,inpatient,1000,ML,0.17,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
EPINEPHrine-lidocaine HCl,00409318301B,NDC,250,RC,,,,inpatient,20,ML,5.61,4.77,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Magnesium Sulfate,00409672923,NDC,250,RC,,,,inpatient,4,GM,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sertraline HCl,60687024201A,NDC,250,RC,,,,inpatient,50,ML,0.26,0.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Penicillin VK,00093412773,NDC,250,RC,,,,inpatient,250,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amitriptyline HCl,29300041901A,NDC,250,RC,,,,inpatient,10,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cefuroxime Sodium,00143997922,NDC,250,RC,,,,inpatient,750,ML,1.49,1.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amvisc,61772059081,NDC,250,RC,,,,inpatient,9.6,ML,123.11,104.64,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
glyBURIDE,00093947753A,NDC,250,RC,,,,inpatient,1.25,ML,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dilTIAZem HCl,24979002906A,NDC,250,RC,,,,inpatient,300,ML,0.41,0.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Januvia,00006027728A,NDC,250,RC,,,,inpatient,100,ML,13.47,11.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Betamethasone Valerate,00168004015,NDC,250,RC,,,,inpatient,1,EA,12.02,10.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
diphenhydrAMINE HCl,00121048900A,NDC,250,RC,,,,inpatient,12.5,ML,4.01,3.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
MS Contin,42858079901,NDC,250,RC,,,,inpatient,100,ML,0.58,0.49,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ciprofloxacin,00409330024A,NDC,250,RC,,,,inpatient,400,ML,2.14,1.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Entresto,00078077720A,NDC,250,RC,,,,inpatient,1,EA,6.42,5.46,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
hydrALAZINE HCl,63323061401,NDC,250,RC,,,,inpatient,20,ML,2.85,2.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
HYDROmorphone HCl,00409131230A,NDC,250,RC,,,,inpatient,2,ML,2.03,1.73,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Castor Oil,00395051592,NDC,250,RC,,,,inpatient,60,ML,2.33,1.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ondansetron HCl,00904655261A,NDC,250,RC,,,,inpatient,8,ML,0.49,0.42,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
CARBOplatin,00703424601A,NDC,250,RC,,,,inpatient,150,ML,17.38,14.77,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
rOPINIRole HCl,62332003331A,NDC,250,RC,,,,inpatient,2,ML,0.59,0.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aspirin,69618001501A,NDC,250,RC,,,,inpatient,325,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Minocycline HCl,60687033665,NDC,250,RC,,,,inpatient,100,ML,0.83,0.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00054023755A,NDC,250,RC,,,,inpatient,0.1,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Slow-Mag,67618010760,NDC,250,RC,,,,inpatient,64,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cromolyn Sodium,61314023710,NDC,250,RC,,,,inpatient,1,EA,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Propranolol HCl,00904655061A,NDC,250,RC,,,,inpatient,10,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
glipiZIDE,51079081020,NDC,250,RC,,,,inpatient,5,ML,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Marcaine Spinal,00409176110,NDC,250,RC,,,,inpatient,7.5,ML,1.06,0.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levothyroxine Sodium,51079044020,NDC,250,RC,,,,inpatient,50,GM,0.46,0.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Phosphates,63323088406A,NDC,250,RC,,,,inpatient,15,EA,0.16,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Decavac,49281029110,NDC,250,RC,,,,inpatient,0.5,ML,2.19,1.86,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Timolol Maleate,61314022505,NDC,250,RC,,,,inpatient,1,EA,1.37,1.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BUPivacaine HCl,00409115901,NDC,250,RC,,,,inpatient,10,ML,0.56,0.48,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Crestor,00310759030,NDC,250,RC,,,,inpatient,40,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levothyroxine Sodium,51079044420A,NDC,250,RC,,,,inpatient,25,GM,0.28,0.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Glimepiride,68084032701A,NDC,250,RC,,,,inpatient,4,ML,0.17,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gentamicin Sulfate,00338050348A,NDC,250,RC,,,,inpatient,80,ML,1.82,1.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cefTRIAXone,55390031010,NDC,250,RC,,,,inpatient,500,ML,0.83,0.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mesalamine,68382043528A,NDC,250,RC,,,,inpatient,800,ML,4.11,3.49,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Havrix Pediatric,58160082511,NDC,250,RC,,,,inpatient,720,UN  ,22.58,19.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
clonazePAM,57664078586,NDC,250,RC,,,,inpatient,0.5,ML,0.45,0.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Optiray 300,00019133206,NDC,250,RC,,,,inpatient,300,ML,0.92,0.78,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vimpat,00131247760A,NDC,250,RC,,,,inpatient,50,ML,6.25,5.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pramipexole Dihydrochloride,13668009390,NDC,250,RC,,,,inpatient,0.5,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Propranolol HCl,69238207907A,NDC,250,RC,,,,inpatient,40,ML,0.47,0.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PACLitaxel,61703034222,NDC,250,RC,,,,inpatient,100,ML,2.12,1.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dilTIAZem HCl,00641601510A,NDC,250,RC,,,,inpatient,125,ML,9.25,7.86,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Theo-24,52244020010,NDC,250,RC,,,,inpatient,200,ML,2.39,2.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
FLUoxetine HCl,54838052340,NDC,250,RC,,,,inpatient,20,ML,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Rivastigmine Tartrate,55111035260A,NDC,250,RC,,,,inpatient,1.5,ML,0.94,0.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dilTIAZem HCl,70860030110A,NDC,250,RC,,,,inpatient,50,ML,2.62,2.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Torsemide,31722053201,NDC,250,RC,,,,inpatient,100,ML,0.27,0.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BUPivacaine HCl,55150017030,NDC,250,RC,,,,inpatient,150,ML,1.08,0.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Polyvinyl Alcohol,00536132594A,NDC,250,RC,,,,inpatient,1,EA,1.71,1.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Trifluridine,61314004475A,NDC,250,RC,,,,inpatient,1,EA,160.59,136.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gardasil 9,00006411903A,NDC,250,RC,,,,inpatient,0.5,ML,268.98,228.63,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vecuronium Bromide,00703291403D,NDC,250,RC,,,,inpatient,100,ML,10,8.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Citric Acid/Sodium Citrate,00121059530A,NDC,250,RC,,,,inpatient,30,ML,4.33,3.68,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Belsomra,00006000530,NDC,250,RC,,,,inpatient,5,ML,4.08,3.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
guanFACINE HCl,00378116001,NDC,250,RC,,,,inpatient,1,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
OXYTOCIN 15 UNITS in LR 250 ML INFU,0269883171285603701A,CDM,250,RC,,,,inpatient,15,UN  ,7,5.95,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
chlorproMAZINE HCl,69238106001A,NDC,250,RC,,,,inpatient,100,ML,2.21,1.88,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amoxicillin,55289002006A,NDC,250,RC,,,,inpatient,500,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
prednisoLONE Sodium Phosphate,00121075908A,NDC,250,RC,,,,inpatient,15,ML,8.02,6.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clotrimazole,51672203701,NDC,250,RC,,,,inpatient,1,EA,34.26,29.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Polymyxin B Sulfate,55150023410A,NDC,250,RC,,,,inpatient,500000,UN  ,6.2,5.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Triamterene/hydroCHLOROthiazide,51079093520,NDC,250,RC,,,,inpatient,1,UN  ,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calcium + D,00904188260,NDC,250,RC,,,,inpatient,1,EA,0.01,0.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
oseltamivir phosphate,47781046813A,NDC,250,RC,,,,inpatient,30,ML,0.84,0.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
SOLU-Medrol 40mg Vial,00009003928A,NDC,250,RC,,,,inpatient,40,ML,142.41,121.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
medroxyPROGESTERone acetate,59762005801A,NDC,250,RC,,,,inpatient,5,ML,0.06,0.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
HYDROcodone bitartrate-ibuprofen,53746014501A,NDC,250,RC,,,,inpatient,1,EA,0.32,0.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Midazolam HCl,00054356699,NDC,250,RC,,,,inpatient,2,ML,0.3,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Potassium Chloride,00338070948A,NDC,250,RC,,,,inpatient,10,UN  ,2.58,2.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Minoxidil,68084020401,NDC,250,RC,,,,inpatient,2.5,ML,0.4,0.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Paxil,60505040205A,NDC,250,RC,,,,inpatient,10,ML,51.92,44.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bicalutamide,16729002301A,NDC,250,RC,,,,inpatient,50,ML,0.22,0.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ayr Saline Nasal,00225052547,NDC,250,RC,,,,inpatient,1,EA,2.78,2.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Potassium Chloride in Dextrose and Sodium Chloride,00990710909,NDC,250,RC,,,,inpatient,40,UN  ,2.29,1.95,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Relenza,00173068101,NDC,250,RC,,,,inpatient,1,EA,55.14,46.87,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
lopinavir-ritonavir,00527194748A,NDC,250,RC,,,,inpatient,2.5,ML,7.61,6.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Metoprolol Tartrate,72572042001A,NDC,250,RC,,,,inpatient,5,ML,0.69,0.59,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin C,00904052361,NDC,250,RC,,,,inpatient,500,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydrocortisone,59762007401A,NDC,250,RC,,,,inpatient,10,ML,0.56,0.48,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Narcan,69547035302,NDC,250,RC,,,,inpatient,4,ML,15.65,13.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ziprasidone HCl,68084010409A,NDC,250,RC,,,,inpatient,40,ML,5.85,4.97,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tobramycin/dexAMETHasone,61314064725A,NDC,250,RC,,,,inpatient,1,EA,54.38,46.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00054023763A,NDC,250,RC,,,,inpatient,10,ML,1.04,0.88,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
aspirin-dipyridamole,68462040560A,NDC,250,RC,,,,inpatient,1,EA,2.65,2.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Viibryd,00456112030,NDC,250,RC,,,,inpatient,20,ML,4.11,3.49,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
methIMAzole,68084027601A,NDC,250,RC,,,,inpatient,10,ML,0.4,0.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Indomethacin,68462030201A,NDC,250,RC,,,,inpatient,50,ML,0.2,0.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dilTIAZem HCl,60687020601A,NDC,250,RC,,,,inpatient,180,ML,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Good Neighbor Pharmacy MaSanti,24385035740,NDC,250,RC,,,,inpatient,355,ML,8,6.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gabapentin,65162010210A,NDC,250,RC,,,,inpatient,300,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Diprivan,63323026929A,NDC,250,RC,,,,inpatient,200000,GM,4.24,3.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nadolol,60687030225A,NDC,250,RC,,,,inpatient,20,ML,1.48,1.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methylene Blue,54288014701A,NDC,250,RC,,,,inpatient,10,ML,169.69,144.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin B12 AvPak,50268085515A,NDC,250,RC,,,,inpatient,1000,GM,0.17,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dihydroergotamine Mesylate,00574085010,NDC,250,RC,,,,inpatient,1,ML,98.89,84.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexAMETHasone Sodium Phosphate,24208072002A,NDC,250,RC,,,,inpatient,1,EA,48.57,41.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
DULoxetine HCl,51991074690A,NDC,250,RC,,,,inpatient,20,ML,0.46,0.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bacitracin Zinc-Polymyxin B Sulfate,24208055555,NDC,250,RC,,,,inpatient,1,EA,56.46,47.99,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl Viscous,00054350049A,NDC,250,RC,,,,inpatient,15,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Liquid C,69618001854A,NDC,250,RC,,,,inpatient,500,ML,0.21,0.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose/Potassium Chloride/Sodium Chloride,00409799803A,NDC,250,RC,,,,inpatient,20,UN  ,1.21,1.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl,63323028420A,NDC,250,RC,,,,inpatient,1000,ML,2.4,2.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose-Sodium Chloride,00338007704,NDC,250,RC,,,,inpatient,1000,ML,2.57,2.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Thiothixene,60219167501A,NDC,250,RC,,,,inpatient,5,ML,0.23,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluocinonide,51672127901A,NDC,250,RC,,,,inpatient,1,EA,5.11,4.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Retrovir,49702021326A,NDC,250,RC,,,,inpatient,10,ML,1.38,1.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Danazol,00527136901A,NDC,250,RC,,,,inpatient,200,ML,3.28,2.79,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tikosyn,00069581043,NDC,250,RC,,,,inpatient,0.25,ML,3.36,2.86,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aspirin,00574703612,NDC,250,RC,,,,inpatient,600,ML,1.28,1.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PHENobarbital,00603150858C,NDC,250,RC,,,,inpatient,2,ML,0.5,0.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bridion,00006542302,NDC,250,RC,,,,inpatient,200,ML,122.17,103.84,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin C,57896084216A,NDC,250,RC,,,,inpatient,500,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Digoxin,00054005746,NDC,250,RC,,,,inpatient,250,GM,0.38,0.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
HC-Neomycin-Polymyxin,61314064610A,NDC,250,RC,,,,inpatient,1,EA,25.84,21.96,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sodium Chloride,00338004918A,NDC,250,RC,,,,inpatient,100,ML,4.51,3.83,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clopidogrel,68084075225A,NDC,250,RC,,,,inpatient,300,ML,10.45,8.88,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Codeine Phosphate/guaiFENesin,00121155040A,NDC,250,RC,,,,inpatient,10,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PremierPro Rx Fluorouracil,63323011768A,NDC,250,RC,,,,inpatient,5000,ML,48.07,40.86,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetaminophen-Codeine Phosphate,00121050405,NDC,250,RC,,,,inpatient,5,ML,0.53,0.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nortriptyline HCl,51672400301A,NDC,250,RC,,,,inpatient,50,ML,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
NovoLOG Mix 70/30,00169368512,NDC,250,RC,,,,inpatient,100,UN  ,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl,68180016613,NDC,250,RC,,,,inpatient,125,ML,4.74,4.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mannitol,00990771513,NDC,250,RC,,,,inpatient,200,ML,19.66,16.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bromocriptine Mesylate,00781532531A,NDC,250,RC,,,,inpatient,2.5,ML,2.55,2.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
"ASCORBIC ACID 1,000 MG TABLET",0270083379854030055,CDM,250,RC,,,,inpatient,1000,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gramicidin/Neomycin/Polymyxin B,24208079062,NDC,250,RC,,,,inpatient,1,EA,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl,62559083080A,NDC,250,RC,,,,inpatient,250,ML,2.3,1.96,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gentamicin Sulfate Pediatric,63323051302,NDC,250,RC,,,,inpatient,20,ML,1.5,1.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
levoFLOXacin in 5% Dextrose,25021013282A,NDC,250,RC,,,,inpatient,500,ML,2.35,2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
metFORMIN HCl,51224000750A,NDC,250,RC,,,,inpatient,500,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
OXYTOCIN 20 UNITS in 0.9% NS 1000 M,0269883370092106708A,CDM,250,RC,,,,inpatient,20,UN  ,9,7.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Kloxxado,59467067901,NDC,250,RC,,,,inpatient,8,ML,59.28,50.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Synthroid,00074662411A,NDC,250,RC,,,,inpatient,100,GM,0.52,0.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetaminophen-Codeine Phosphate,00406048462,NDC,250,RC,,,,inpatient,1,EA,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Revatio,00069419068,NDC,250,RC,,,,inpatient,20,ML,14.67,12.47,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Labetalol HCl,00409226720,NDC,250,RC,,,,inpatient,5,ML,1.55,1.32,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Melatonin,74312002832,NDC,250,RC,,,,inpatient,1,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Xifaxan,65649030103B,NDC,250,RC,,,,inpatient,400,ML,33,28.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Warfarin Sodium,65162076310A,NDC,250,RC,,,,inpatient,2.5,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Anagrelide HCl,13668046201A,NDC,250,RC,,,,inpatient,1,ML,1.7,1.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clinimix 8/14,00338018001,NDC,250,RC,,,,inpatient,1000,ML,35.78,30.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zemplar,00074903630,NDC,250,RC,,,,inpatient,1,GM,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prazosin HCl,00093406901A,NDC,250,RC,,,,inpatient,5,ML,0.42,0.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Enalaprilat,00143978710,NDC,250,RC,,,,inpatient,1.25,ML,3.68,3.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tracleer,66215010206,NDC,250,RC,,,,inpatient,125,ML,49.5,42.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluconazole,59762502901A,NDC,250,RC,,,,inpatient,10,ML,0.37,0.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cefuroxime Sodium,00143997722,NDC,250,RC,,,,inpatient,1.5,GM,3.06,2.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Glydo,25021067376,NDC,250,RC,,,,inpatient,6,ML,4.95,4.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BUPivacaine HCl,00409116301,NDC,250,RC,,,,inpatient,250,ML,1.37,1.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Asmanex Twisthaler,78206011404A,NDC,250,RC,,,,inpatient,1,EA,36.25,30.81,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
lamiVUDine,54838056670A,NDC,250,RC,,,,inpatient,10,ML,0.45,0.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
carBAMazepine,60687059421A,NDC,250,RC,,,,inpatient,400,ML,1.26,1.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aspirin,00574703412,NDC,250,RC,,,,inpatient,300,ML,1.24,1.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Buprenorphine,60687049221A,NDC,250,RC,,,,inpatient,8,ML,6.88,5.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Insta-Glucose,00187074633A,NDC,250,RC,,,,inpatient,24,GM,3.54,3.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Magnesium Sulfate-Dextrose,00409672723,NDC,250,RC,,,,inpatient,1,GM,2.08,1.77,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin D3 AvPak,50268086815,NDC,250,RC,,,,inpatient,5000,UN  ,0.21,0.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,00409427902,NDC,250,RC,,,,inpatient,10,ML,1.76,1.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Midazolam HCl,00409259605B,NDC,250,RC,,,,inpatient,2.5,ML,3.5,2.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Divalproex Sodium,00832712301A,NDC,250,RC,,,,inpatient,250,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fomepizole,70710147801A,NDC,250,RC,,,,inpatient,1,GM,561.77,477.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prostin VR Pediatric,00009316906,NDC,250,RC,,,,inpatient,500,GM,135.33,115.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
HYDROmorphone HCl,00409335601,NDC,250,RC,,,,inpatient,2,ML,0.83,0.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
rOPINIRole HCl,68462025501A,NDC,250,RC,,,,inpatient,1,ML,0.51,0.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
chlorproMAZINE HCl,51079013020,NDC,250,RC,,,,inpatient,50,ML,0.22,0.19,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Propofol,63323027065A,NDC,250,RC,,,,inpatient,1000000,GM,20.35,17.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lithium Carbonate,00054852625,NDC,250,RC,,,,inpatient,150,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Rosuvastatin Calcium,27808015501A,NDC,250,RC,,,,inpatient,5,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amoxicillin,00781603958A,NDC,250,RC,,,,inpatient,125,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cleocin Phosphate,00009087026A,NDC,250,RC,,,,inpatient,300,ML,2.25,1.91,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Naropin,63323028565E,NDC,250,RC,,,,inpatient,50,ML,31.46,26.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Desmopressin Acetate,69918010101A,NDC,250,RC,,,,inpatient,0.1,ML,0.43,0.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Infumorph 200,60977011474,NDC,250,RC,,,,inpatient,10,ML,6.5,5.53,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Magnesium Sulfate,63323006402A,NDC,250,RC,,,,inpatient,1,GM,1.04,0.88,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ziagen,49702022248,NDC,250,RC,,,,inpatient,20,ML,0.59,0.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Doxazosin Mesylate,60505009400A,NDC,250,RC,,,,inpatient,2,ML,0.52,0.44,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vecuronium Bromide,00703291403B,NDC,250,RC,,,,inpatient,100,ML,26,22.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Agrylin,54092006301,NDC,250,RC,,,,inpatient,0.5,ML,1.68,1.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Leflunomide,23155004303,NDC,250,RC,,,,inpatient,10,ML,0.27,0.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nabumetone,69097096507A,NDC,250,RC,,,,inpatient,500,ML,0.17,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Neomycin Sulfate,00093117701A,NDC,250,RC,,,,inpatient,500,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Glimepiride,68084078825A,NDC,250,RC,,,,inpatient,1,ML,0.21,0.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
levoFLOXacin,72578010092A,NDC,250,RC,,,,inpatient,750,ML,0.31,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Quinapril,43547041009A,NDC,250,RC,,,,inpatient,5,ML,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zonisamide,68001024200A,NDC,250,RC,,,,inpatient,25,ML,0.53,0.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tikosyn,00069580043A,NDC,250,RC,,,,inpatient,0.125,ML,3.36,2.86,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Benztropine Mesylate,68084038101A,NDC,250,RC,,,,inpatient,0.5,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clarithromycin,00781196160,NDC,250,RC,,,,inpatient,250,ML,0.32,0.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Repaglinide,65862067001A,NDC,250,RC,,,,inpatient,0.5,ML,2.35,2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
INVanz,00006384371A,NDC,250,RC,,,,inpatient,1,GM,75.92,64.53,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
OLANZapine,68084072301A,NDC,250,RC,,,,inpatient,5,ML,3.59,3.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mirtazapine,68084011901A,NDC,250,RC,,,,inpatient,15,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PARoxetine HCl,68084004401,NDC,250,RC,,,,inpatient,10,ML,0.6,0.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
fluPHENAZine HCl,63323028110,NDC,250,RC,,,,inpatient,2.5,ML,68.1,57.89,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Torsemide,31722052901,NDC,250,RC,,,,inpatient,5,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ondansetron,00054006447A,NDC,250,RC,,,,inpatient,4,ML,0.1,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gentak,17478028435,NDC,250,RC,,,,inpatient,1,EA,8.85,7.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Midazolam HCl,00409259605E,NDC,250,RC,,,,inpatient,100,ML,7.5,6.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Amitriptyline HCl,51079056320,NDC,250,RC,,,,inpatient,100,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tobramycin,61314064305,NDC,250,RC,,,,inpatient,1,EA,0.09,0.08,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl-Dextrose,00338040903A,NDC,250,RC,,,,inpatient,2000,ML,4.11,3.49,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prograf,00469065773,NDC,250,RC,,,,inpatient,5,ML,8.93,7.59,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Relpax,00049234045A,NDC,250,RC,,,,inpatient,40,ML,22.98,19.53,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zithromax,00069315083A,NDC,250,RC,,,,inpatient,500,ML,5.86,4.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Indocin,69344010233,NDC,250,RC,,,,inpatient,50,ML,276.41,234.95,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gentamicin Sulfate,45802005635A,NDC,250,RC,,,,inpatient,1,EA,10.5,8.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nutrilyte II,00517202025,NDC,250,RC,,,,inpatient,20,ML,1.37,1.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
NIFEdipine,50742026201A,NDC,250,RC,,,,inpatient,90,ML,0.61,0.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fondaparinux Sodium,70710151606,NDC,250,RC,,,,inpatient,7.5,ML,52.45,44.58,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
EPINEPHrine HCl,00409724101,NDC,250,RC,,,,inpatient,1000,GM,9.49,8.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Spikevax 2023-2024 Formula,80777010293,NDC,771,RC,,,,outpatient,50,GM,129.5,110.08,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",55,3783,,facility
Norvir,00074339930,NDC,250,RC,,,,inpatient,100,ML,8.32,7.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Good Neighbor Pharmacy Liquid Wart Remover,46122036229,NDC,250,RC,,,,inpatient,1,EA,3.67,3.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nicorette,00135050904,NDC,250,RC,,,,inpatient,4,ML,0.36,0.31,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vecuronium Bromide,47335093144A,NDC,250,RC,,,,inpatient,10,ML,6.86,5.83,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pitocin,42023011602,NDC,250,RC,,,,inpatient,10,UN  ,11.19,9.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,63323020110,NDC,250,RC,,,,inpatient,10,ML,0.2,0.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Milrinone Lactate in Dextrose,00143971910A,NDC,250,RC,,,,inpatient,20000,GM,11.49,9.77,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clarithromycin,00781602352A,NDC,250,RC,,,,inpatient,250,ML,1.2,1.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Naproxen AvPak,50268059415A,NDC,250,RC,,,,inpatient,250,ML,0.16,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Water For Injection,00409488710,NDC,250,RC,,,,inpatient,10,ML,1.1,0.94,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Clindamycin Palmitate HCl,65862059602A,NDC,250,RC,,,,inpatient,75,ML,0.43,0.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Erythromycin,24208091055A,NDC,250,RC,,,,inpatient,1,EA,7.6,6.46,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Medrol,00009002201,NDC,250,RC,,,,inpatient,8,ML,0.99,0.84,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
FLUCYTOSINE 500 MG CAPSULE,0270028542494034003A,CDM,250,RC,,,,inpatient,500,ML,39.63,33.69,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aquaphor,72140045231A,NDC,250,RC,,,,inpatient,1,EA,5.99,5.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prochlorperazine Maleate,59746011306A,NDC,250,RC,,,,inpatient,5,ML,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Heparin Lock Flush,64253033335D,NDC,250,RC,,,,inpatient,4,ML,1,0.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl (Premix),70594005702,NDC,250,RC,,,,inpatient,1250,ML,15.61,13.27,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
metroNIDAZOLE,50111033402,NDC,250,RC,,,,inpatient,500,ML,0.41,0.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Granisetron Hydrochloride,67457086301,NDC,250,RC,,,,inpatient,1,ML,2.99,2.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aminophylline,00409592101,NDC,250,RC,,,,inpatient,250,ML,9.48,8.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Neostigmine Methylsulfate,63323041310B,NDC,250,RC,,,,inpatient,0.5,ML,30.51,25.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Doxepin HCl,51079043720,NDC,250,RC,,,,inpatient,25,ML,0.08,0.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
prednisoLONE Acetate,61314063705,NDC,250,RC,,,,inpatient,1,EA,0.33,0.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Mestinon Timespan,00187301330,NDC,250,RC,,,,inpatient,180,ML,3.19,2.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Premarin,00046110081,NDC,250,RC,,,,inpatient,0.3,ML,2.96,2.52,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Papaverine HCl,00517400225A,NDC,250,RC,,,,inpatient,30,ML,10.33,8.78,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Prezista,59676056630,NDC,250,RC,,,,inpatient,800,ML,65.84,55.96,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
traMADol HCl,51079099120A,NDC,250,RC,,,,inpatient,50,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dilTIAZem HCl,00641601310,NDC,250,RC,,,,inpatient,25,ML,0.89,0.76,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dakin's Solution Full Strength,00436094616,NDC,250,RC,,,,inpatient,1,EA,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PremierPro Rx DOCEtaxel,00409173201,NDC,250,RC,,,,inpatient,160,ML,63.65,54.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
oxyBUTYnin Chloride,54838051080,NDC,250,RC,,,,inpatient,5,ML,0.16,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Suboxone,12496120203A,NDC,250,RC,,,,inpatient,1,EA,1.62,1.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluconazole,00409468818A,NDC,250,RC,,,,inpatient,200,ML,18.19,15.46,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Benzonatate,68084021411A,NDC,250,RC,,,,inpatient,100,ML,1.21,1.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levothyroxine Sodium,63323064710A,NDC,250,RC,,,,inpatient,200,GM,126.85,107.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ketorolac Tromethamine,60760031420A,NDC,250,RC,,,,inpatient,10,ML,0.53,0.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
OXcarbazepine,68084084501A,NDC,250,RC,,,,inpatient,150,ML,0.16,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
TEGretol-XR,00078051005,NDC,250,RC,,,,inpatient,100,ML,0.46,0.39,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
SOLU-Medrol 1GM Vial,00009001820A,NDC,250,RC,,,,inpatient,1000,ML,1.5,1.28,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,55150016402,NDC,250,RC,,,,inpatient,40,ML,1.48,1.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ferric Subsulfate,62991279601,NDC,250,RC,,,,inpatient,500,ML,30.51,25.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
predniSONE,60687014501A,NDC,250,RC,,,,inpatient,20,ML,0.17,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Thiamine HCl,67457019602A,NDC,250,RC,,,,inpatient,200,ML,3.13,2.66,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Suboxone,12496120203,NDC,250,RC,,,,inpatient,1,EA,1.61,1.37,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
EPINEPHrine,54288010310A,NDC,250,RC,,,,inpatient,1000,GM,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dilantin Infatabs,00071000740,NDC,250,RC,,,,inpatient,50,ML,0.62,0.53,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ondansetron,00641607825A,NDC,250,RC,,,,inpatient,4,ML,0.31,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
hydrOXYzine Pamoate,00185067401A,NDC,250,RC,,,,inpatient,25,ML,0.27,0.23,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pramipexole Dihydrochloride,13668009590,NDC,250,RC,,,,inpatient,1.5,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Loperamide HCl,68094002962,NDC,250,RC,,,,inpatient,1,ML,1.6,1.36,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sarna Sensitive,00316023075,NDC,250,RC,,,,inpatient,1,EA,6.55,5.57,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Adenosine,63323065104,NDC,250,RC,,,,inpatient,6,ML,5.65,4.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Provisc,08065183085,NDC,250,RC,,,,inpatient,8.5,ML,64.49,54.82,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vitamin B6,80681002500A,NDC,250,RC,,,,inpatient,100,ML,0.01,0.01,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Midazolam HCl,00641605910,NDC,250,RC,,,,inpatient,5,ML,0.6,0.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ziprasidone HCl,68084010309A,NDC,250,RC,,,,inpatient,20,ML,11.46,9.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Dextrose/Sodium Chloride,63323086710A,NDC,250,RC,,,,inpatient,1000,ML,5,4.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexAMETHasone,54879000308A,NDC,250,RC,,,,inpatient,0.5,ML,0.17,0.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
EPINEPHrine-lidocaine HCl,00409317802,NDC,250,RC,,,,inpatient,30,ML,1.65,1.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Fluconazole,68084072801A,NDC,250,RC,,,,inpatient,100,ML,0.13,0.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ampicillin Sodium,65219001610,NDC,250,RC,,,,inpatient,500,ML,1.32,1.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sudogest,00904672846A,NDC,250,RC,,,,inpatient,60,ML,0.03,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
cefOXitin Sodium,00264312511,NDC,250,RC,,,,inpatient,2,GM,18.31,15.56,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Morphine Sulfate,00406833062,NDC,250,RC,,,,inpatient,30,ML,3.29,2.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine,00591352530A,NDC,250,RC,,,,inpatient,1,UN  ,2.63,2.24,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
HYALURONATE SODIUM 23 MG/1 ML SYRIN,0269928900016031660,CDM,250,RC,,,,inpatient,23,ML,63.51,53.98,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Atenolol,51079068420,NDC,250,RC,,,,inpatient,50,ML,0.07,0.06,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sensipar,55513007330,NDC,250,RC,,,,inpatient,30,ML,0.24,0.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Primidone,00527123101A,NDC,250,RC,,,,inpatient,250,ML,0.26,0.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Children's Tylenol,50580061401A,NDC,250,RC,,,,inpatient,160,ML,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BUPivacaine HCl with EPINEPHrine,00409904201,NDC,250,RC,,,,inpatient,10,ML,4.96,4.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Digoxin,68084068001A,NDC,250,RC,,,,inpatient,0.25,ML,0.75,0.64,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Miconazole-3,00472173803,NDC,250,RC,,,,inpatient,200,ML,12,10.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gentamicin Sulfate,24208058060A,NDC,250,RC,,,,inpatient,1,EA,2.23,1.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
fluPHENAZine HCl,70710148901A,NDC,250,RC,,,,inpatient,2.5,ML,0.26,0.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
methazolAMIDE,00574079101A,NDC,250,RC,,,,inpatient,50,ML,1.78,1.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ketorolac Tromethamine,61314012605A,NDC,250,RC,,,,inpatient,1,EA,10.36,8.81,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Torsemide,68084053901A,NDC,250,RC,,,,inpatient,20,ML,0.3,0.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Methocarbamol,31722053301A,NDC,250,RC,,,,inpatient,500,ML,0.19,0.16,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lovenox,00075062300A,NDC,250,RC,,,,inpatient,100,ML,4.74,4.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
RisperDAL Consta,50458030811,NDC,250,RC,,,,inpatient,50,ML,62.55,53.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Trihexyphenidyl HCl,70954021110A,NDC,250,RC,,,,inpatient,5,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Anti-Itch Cream,45802035803,NDC,250,RC,,,,inpatient,1,EA,2.75,2.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Doxycycline Hyclate,00143980305A,NDC,250,RC,,,,inpatient,100,ML,0.56,0.48,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Miostat,00065002315,NDC,250,RC,,,,inpatient,1.5,ML,12.71,10.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ciprofloxacin,65862007601A,NDC,250,RC,,,,inpatient,250,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
VESIcare,51248015101,NDC,250,RC,,,,inpatient,10,ML,4.82,4.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetic Acid,52817081615A,NDC,250,RC,,,,inpatient,1,EA,14.05,11.94,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hydrocortisone,00168001631,NDC,250,RC,,,,inpatient,1,EA,2.84,2.41,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cyclobenzaprine HCl,51079064420A,NDC,250,RC,,,,inpatient,10,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Famotidine,00338519741,NDC,250,RC,,,,inpatient,20,ML,4.16,3.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
MORPHINE SULFATE IN NS 100 MG/100 M,0270073770092138036,CDM,250,RC,,,,inpatient,100,ML,8.45,7.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Protonix IV,00008092360A,NDC,250,RC,,,,inpatient,40,ML,2.06,1.75,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
HYDROmorphone HCl,00409128331,NDC,250,RC,,,,inpatient,1,ML,2.24,1.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Tetracycline HCl,67405066110,NDC,250,RC,,,,inpatient,500,ML,5.93,5.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Calcium Gluconate-Sodium Chloride,44567062224,NDC,250,RC,,,,inpatient,1000,ML,8.06,6.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Benzonatate,42806071501,NDC,250,RC,,,,inpatient,200,ML,0.18,0.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
acetaZOLAMIDE,50742023301A,NDC,250,RC,,,,inpatient,500,ML,3.25,2.76,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bystolic,00456141030A,NDC,250,RC,,,,inpatient,10,ML,4.84,4.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
fluvoxaMINE Maleate,62559015801A,NDC,250,RC,,,,inpatient,25,ML,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ketoconazole,45802046564,NDC,250,RC,,,,inpatient,1,EA,8.68,7.38,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
GaviLyte-G with Flavor Pack,43386009019A,NDC,250,RC,,,,inpatient,4000,ML,19,16.15,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
pyRIDostigmine Bromide,68382065906A,NDC,250,RC,,,,inpatient,60,ML,0.21,0.18,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Uloric,64764067730,NDC,250,RC,,,,inpatient,80,ML,6.97,5.92,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Coreg CR,80725038513,NDC,250,RC,,,,inpatient,20,ML,4.76,4.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Terazosin HCl,59746038506A,NDC,250,RC,,,,inpatient,5,ML,0.05,0.04,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Midodrine HCl,00245021111A,NDC,250,RC,,,,inpatient,2.5,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetic Acid,51552005106A,NDC,250,RC,,,,inpatient,500,ML,1.94,1.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
FML Forte Liquifilm,11980022805,NDC,250,RC,,,,inpatient,1,EA,2.12,1.8,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Isentress,00006360361,NDC,250,RC,,,,inpatient,100,ML,6.86,5.83,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Haloperidol,51079073620,NDC,250,RC,,,,inpatient,5,ML,0.71,0.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
metroNIDAZOLE,51672411606,NDC,250,RC,,,,inpatient,1,EA,21.13,17.96,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pneumovax 23,00006494300,NDC,771,RC,,,,outpatient,0.5,ML,110.33,93.78,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",55,3783,,facility
Amiodarone HCl,51862024030,NDC,250,RC,,,,inpatient,100,ML,0.34,0.29,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Piperacillin and Tazobactam,61990015001A,NDC,250,RC,,,,inpatient,40.5,GM,105.33,89.53,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bumetanide,00185012901A,NDC,250,RC,,,,inpatient,1,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
lamoTRIgine,68084031901A,NDC,250,RC,,,,inpatient,100,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Benztropine Mesylate,00143972905,NDC,250,RC,,,,inpatient,2,ML,11.24,9.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levobunolol HCl,24208050505B,NDC,250,RC,,,,inpatient,1,EA,0.02,0.02,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pepto-Bismol,37000047508A,NDC,250,RC,,,,inpatient,524,ML,1.34,1.14,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Norvir,00074234030,NDC,250,RC,,,,inpatient,100,ML,8.32,7.07,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Vancomycin HCl,63323031461,NDC,250,RC,,,,inpatient,10,GM,31.46,26.74,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Hurricaine One,00283061026,NDC,250,RC,,,,inpatient,1,EA,9.34,7.94,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Cerebyx,00069600121A,NDC,250,RC,,,,inpatient,500,ML,18.64,15.84,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Lidocaine HCl,17478071110A,NDC,250,RC,,,,inpatient,1,EA,4.51,3.83,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Bumetanide,00641600810,NDC,250,RC,,,,inpatient,1,ML,0.63,0.54,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Ferrous Gluconate,00574050811A,NDC,250,RC,,,,inpatient,324,ML,0.04,0.03,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Armour Thyroid,00456045801,NDC,250,RC,,,,inpatient,30,ML,0.25,0.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Acetone,00395001994,NDC,250,RC,,,,inpatient,120,ML,4.63,3.94,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Sebulex,10631010807,NDC,250,RC,,,,inpatient,1,EA,1.48,1.26,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Naropin,63323028565B,NDC,250,RC,,,,inpatient,50,ML,15.55,13.22,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
predniSONE,60687012201A,NDC,250,RC,,,,inpatient,5,ML,0.14,0.12,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Timolol Maleate,61314022605A,NDC,250,RC,,,,inpatient,1,EA,4.91,4.17,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Exelon,00078050215,NDC,250,RC,,,,inpatient,1,EA,10.03,8.53,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
VIAL-MATE REC DEVICE 1 EACH,0269994785412027383,CDM,250,RC,,,,inpatient,1,EA,2.48,2.11,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
dexAMETHasone,00054818125,NDC,250,RC,,,,inpatient,1.5,ML,0.12,0.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gleevec,00078040134,NDC,250,RC,,,,inpatient,100,ML,47.85,40.67,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Nevirapine,00378405091A,NDC,250,RC,,,,inpatient,200,ML,0.11,0.09,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Levothyroxine Sodium,63323064810A,NDC,250,RC,,,,inpatient,100,GM,63.14,53.67,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Gabapentin,42192060816A,NDC,250,RC,,,,inpatient,250,ML,0.29,0.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Pentoxifylline,00904544861A,NDC,250,RC,,,,inpatient,400,ML,0.15,0.13,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Intralipid,00338051909A,NDC,250,RC,,,,inpatient,250,ML,10.84,9.21,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Exparel,65250026609,NDC,250,RC,,,,inpatient,266,ML,335.95,285.56,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Zithromax,00069315083,NDC,250,RC,,,,inpatient,500,ML,1.65,1.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
hydrOXYzine HCl,60432015016A,NDC,250,RC,,,,inpatient,10,ML,0.99,0.84,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
OXcarbazepine,62756018488A,NDC,250,RC,,,,inpatient,300,ML,0.54,0.46,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Belsomra,00006032530,NDC,250,RC,,,,inpatient,15,ML,10.5,8.93,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
melphalan,47781020050A,NDC,636,RC,J7600,HCPCS,,outpatient,2,ML,8.59,7.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,3783,,facility
Bebtelovimab,00002758901,NDC,636,RC,Q0222,HCPCS,,outpatient,175,ML,2100,1785,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,3783,,facility
Ontak,62856060301,NDC,636,RC,J9160,HCPCS,,outpatient,300,GM,0.5,0.43,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,3783,,facility
Soliris,25682000101,NDC,636,RC,J1300,HCPCS,,outpatient,300,ML,4315.44,3668.12,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",228.94,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,228.94,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",228.94,3783,,facility
Xeloda,00004110150,NDC,636,RC,J8521,HCPCS,,outpatient,500,ML,32.47,27.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,3783,,facility
HyperRAB,13533031805,NDC,636,RC,90375,CPT,,outpatient,300,UN  ,2091.97,1778.17,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,237.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,293.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1161.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,293.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,308.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,308.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,237.96,3783,,facility
Fetroja,59630026610,NDC,636,RC,J0699,HCPCS,,outpatient,1,GM,188.98,160.63,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.01,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2.01,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.01,3783,,facility
Monoferric,73594931001,NDC,636,RC,J1437,HCPCS,,outpatient,1000,ML,1363.92,1159.33,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,19.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,94.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,23.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.4,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24.4,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19.41,3783,,facility
DigiFab,50633012011A,NDC,636,RC,J1162,HCPCS,,outpatient,40,ML,4507.03,3830.98,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4391.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5425.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21443.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5425.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4128.19,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4128.19,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5166.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,21443.01,,facility
Empliciti,00003452211,NDC,636,RC,J9176,HCPCS,,outpatient,400,ML,1992.83,1693.91,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.86,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.86,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.83,3783,,facility
Idamycin PFS,00013258691,NDC,636,RC,J9211,HCPCS,,outpatient,10,ML,7.33,6.23,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Albutein,68516521601,NDC,636,RC,P9047,HCPCS,,outpatient,12.5,GM,37.5,31.88,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,45.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,55.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,220.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,55.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52.45,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37.5,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37.5,3783,,facility
Trodelvy,55135013201,NDC,636,RC,J9317,HCPCS,,outpatient,180,ML,1583.47,1345.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,31.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,38.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,153.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,38.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.26,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31.26,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.26,3783,,facility
Trazimera,00069030501,NDC,636,RC,Q5116,HCPCS,,outpatient,21,ML,56.77,48.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.79,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55.79,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.97,3783,,facility
Cytarabine,55390013301,NDC,636,RC,J9100,HCPCS,,outpatient,1,GM,9.77,8.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Zoladex,70720095036,NDC,636,RC,J9202,HCPCS,,outpatient,3.6,ML,751.82,639.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,660.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,816.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3226.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,816.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,543.16,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,543.16,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,543.16,3783,,facility
eptifibatide,70436002780A,NDC,636,RC,J1327,HCPCS,,outpatient,75,ML,80.15,68.13,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.11,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2.11,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.11,3783,,facility
Truxima,63459010450,NDC,636,RC,Q5115,HCPCS,,outpatient,500,ML,928.42,789.16,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,25.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,125.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,31.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,57.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25.63,3783,,facility
Etoposide,16729011431A,NDC,636,RC,J9181,HCPCS,,outpatient,100,ML,6.07,5.16,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Hylenex,18657011704A,NDC,636,RC,J3473,HCPCS,,outpatient,150,UN  ,51.34,43.64,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Eligard,62935022305,NDC,636,RC,J9217,HCPCS,,outpatient,22.5,ML,271.62,230.88,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,145.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,179.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,708.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,179.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,200.73,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,200.73,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.16,3783,,facility
Andexxa,69853010201,NDC,636,RC,J7169,HCPCS,,outpatient,200,ML,2500,2125,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,111.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,137.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,545.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,137.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,288.47,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,288.47,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,131.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,111.66,3783,,facility
Udenyca,70114010101,NDC,636,RC,Q5111,HCPCS,,outpatient,6,ML,1101.81,936.54,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,137.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,170.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,672.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,170.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202.1,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,202.1,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,161.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,137.69,3783,,facility
Synagis,66658023001A,NDC,636,RC,90375,CPT,,outpatient,50,ML,1269.45,1079.03,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,237.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,293.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1161.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,293.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,308.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,308.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,237.96,3783,,facility
Treanda,63459039120,NDC,636,RC,J9033,HCPCS,,outpatient,100,ML,1137.36,966.76,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.69,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20.69,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1.74,3783,,facility
Avastin,50242006101,NDC,636,RC,J9035,HCPCS,,outpatient,400,ML,2217.74,1885.08,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,62.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,77.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,305.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,77.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,67.86,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,67.86,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.59,3783,,facility
Heparin Sodium,00641039112A,NDC,636,RC,J1644,HCPCS,,outpatient,1000,UN  ,0.8,0.68,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Herceptin,50242013201,NDC,636,RC,J9355,HCPCS,,outpatient,150,ML,708.34,602.09,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,62.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,77.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,304.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,77.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,86.41,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,86.41,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.46,3783,,facility
Enhertu,65597040601,NDC,636,RC,J9358,HCPCS,,outpatient,100,ML,1828.79,1554.47,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,26.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,32.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.6,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24.6,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.6,3783,,facility
Boostrix,58160084252A,NDC,636,RC,90715,CPT,,outpatient,0.5,ML,36.67,31.17,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Cancidas,00006382210,NDC,636,RC,J0637,HCPCS,,outpatient,50,ML,34.03,28.93,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Xolair,50242004062,NDC,636,RC,J2357,HCPCS,,outpatient,150,ML,674.35,573.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,38.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,188.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,47.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37.51,3783,,facility
Zoledronic Acid,25021080166A,NDC,636,RC,J3489,HCPCS,,outpatient,4,ML,22.85,19.42,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
bortezomib,25021024410B,NDC,636,RC,J9041,HCPCS,,outpatient,2.5,ML,32.96,28.02,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",44.79,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32.96,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",32.96,3783,,facility
Ambisome,00469305130,NDC,636,RC,J0289,HCPCS,,outpatient,50,ML,157.83,134.16,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,17.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,85.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,21.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.47,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29.47,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.61,3783,,facility
SandoSTATIN LAR Depot,00078082581,NDC,636,RC,J2353,HCPCS,,outpatient,30,ML,1467.14,1247.07,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,169.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,209.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,826.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,209.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,206.56,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,206.56,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,169.29,3783,,facility
Premarin Intravenous,00046074905,NDC,636,RC,J1410,HCPCS,,outpatient,25,ML,108.19,91.96,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,333,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,411.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1625.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,411.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,341.5,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,108.19,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108.19,3783,,facility
Lipodox 50,47335008350A,NDC,636,RC,Q2049,HCPCS,,outpatient,50,ML,534.08,453.97,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,253.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,313.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1239.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,313.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,311.04,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,311.04,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,253.93,3783,,facility
Ruxience,00069024901,NDC,636,RC,Q5119,HCPCS,,outpatient,500,ML,1195.11,1015.84,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,11.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,56.37,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,56.37,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.28,3783,,facility
Reclast,00078043561,NDC,636,RC,J3489,HCPCS,,outpatient,5,ML,804.53,683.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Ziextenzo,61314086601,NDC,636,RC,Q5120,HCPCS,,outpatient,6,ML,1142.09,970.78,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,101.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,125.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,495.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,125.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,222.86,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,222.86,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,101.4,3783,,facility
Synvisc,58468009001,NDC,636,RC,J7325,HCPCS,,outpatient,16,ML,406.32,345.37,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.43,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10.43,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.43,3783,,facility
Vibativ,66220031522,NDC,636,RC,J3095,HCPCS,,outpatient,750,ML,400.53,340.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.4,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.4,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.26,3783,,facility
Somatuline Depot,15054112004,NDC,636,RC,J1930,HCPCS,,outpatient,120,ML,3325.39,2826.58,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,30.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,146.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,37.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,66.18,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,66.18,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.08,3783,,facility
Adcetris,51144005001,NDC,636,RC,J9042,HCPCS,,outpatient,50,ML,3290.14,2796.62,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,228.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,281.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1114.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,281.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,196.55,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,196.55,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,196.55,3783,,facility
Dacarbazine,00143924510A,NDC,636,RC,J9130,HCPCS,,outpatient,200,ML,5.61,4.77,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
HyperHEP B,13533063603,NDC,636,RC,90371,CPT,,outpatient,110,UN  ,84.94,72.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,117.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,144.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,571.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,144.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135.59,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,84.94,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,84.94,3783,,facility
Injectafer,00517065001,NDC,636,RC,J1439,HCPCS,,outpatient,750,ML,589.31,500.91,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,0.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1.12,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1.12,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.95,3783,,facility
Venofer,00517234010,NDC,636,RC,J1756,HCPCS,,outpatient,100,ML,79.91,67.92,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Kyprolis,76075010201,NDC,636,RC,J9047,HCPCS,,outpatient,30,ML,891.5,757.78,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,47.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,58.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,230.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,58.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41.11,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41.11,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41.11,3783,,facility
Lupron Depot,00074364103B,NDC,636,RC,J1950,HCPCS,,outpatient,3.75,ML,74.2,63.07,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1499.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1852.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7320.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1852.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1366.01,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,74.2,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1763.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,74.2,7320.06,,facility
Tecentriq,50242091701,NDC,636,RC,J9022,HCPCS,,outpatient,1200,ML,7382.51,6275.13,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,79.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,98.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,389.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,98.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,79.58,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,79.58,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,79.58,3783,,facility
dexAMETHasone Sodium Phosphate,63323050601A,NDC,636,RC,J1100,HCPCS,,outpatient,10,ML,1.06,0.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Fasenra PFS,00310173030,NDC,636,RC,J0517,HCPCS,,outpatient,30,ML,5350.88,4548.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,139.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,172.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,680.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,172.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,167.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,167.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,163.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,139.37,3783,,facility
Oxaliplatin,25021023310A,NDC,636,RC,J9263,HCPCS,,outpatient,50,ML,1.41,1.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
palonosetron hcl,60505619301A,NDC,636,RC,J2469,HCPCS,,outpatient,0.25,ML,0.13,0.11,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Baclofen,70710128500A,NDC,636,RC,J0475,HCPCS,,outpatient,10,ML,0.33,0.28,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,154.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,190.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,753.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,190.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,181.57,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,0.33,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,181.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.33,3783,,facility
Darzalex Faspro,57894050301,NDC,636,RC,J9144,HCPCS,,outpatient,15,ML,6413.42,5451.41,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,46.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,57.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,228.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,57.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45.03,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45.03,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45.03,3783,,facility
Bal In Oil,17478052603A,NDC,636,RC,J0470,HCPCS,,outpatient,300,ML,81.63,69.39,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
DOXOrubicin HCl Liposome,47335004940A,NDC,636,RC,Q2049,HCPCS,,outpatient,20,ML,801.91,681.62,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,253.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,313.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1239.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,313.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,311.04,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,311.04,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,253.93,3783,,facility
Darzalex,57894050205,NDC,636,RC,J9145,HCPCS,,outpatient,100,ML,365.04,310.28,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,60.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,74.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,293.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,74.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57.22,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,57.22,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57.22,3783,,facility
Monjuvi,73535020801,NDC,636,RC,J9349,HCPCS,,outpatient,200,ML,915.62,778.28,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,12.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,14.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.8,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12.8,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.1,3783,,facility
Halaven,62856038901,NDC,636,RC,J9179,HCPCS,,outpatient,1,ML,833.49,708.47,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,61.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,76.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,301.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,76.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,127.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,127.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,61.72,3783,,facility
Retacrit,00069130710,NDC,636,RC,Q5106,HCPCS,,outpatient,4000,UN  ,63.69,54.14,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.13,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.13,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.43,3783,,facility
Trisenox,63459060010,NDC,636,RC,J9017,HCPCS,,outpatient,10,ML,386.8,328.78,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",12.81,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12.81,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",12.81,3783,,facility
Topotecan HCl,16729015131A,NDC,636,RC,J9351,HCPCS,,outpatient,4,ML,709.19,602.81,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Abraxane,68817013450A,NDC,636,RC,J9264,HCPCS,,outpatient,100,ML,890.8,757.18,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.04,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.04,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.95,3783,,facility
Libtayo,61755000801,NDC,636,RC,J9119,HCPCS,,outpatient,350,ML,7048.8,5991.48,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,24.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,119.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,30.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.39,3783,,facility
Mvasi,55513020601,NDC,636,RC,Q5107,HCPCS,,outpatient,100,ML,136.2,115.77,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,20.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,98.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,25.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.77,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39.77,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.26,3783,,facility
mitoMYcin,55390025201,NDC,636,RC,J9280,HCPCS,,outpatient,20,ML,111.44,94.72,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,22.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,27.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.66,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50.66,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.18,3783,,facility
Ixempra,70020191001A,NDC,636,RC,J9207,HCPCS,,outpatient,15,ML,914.27,777.13,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,118.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,146.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,580.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,146.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,114.19,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,114.19,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,114.19,3783,,facility
eptifibatide,70436002680A,NDC,636,RC,J1327,HCPCS,,outpatient,10,ML,25.61,21.77,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.11,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2.11,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.11,3783,,facility
Velcade,63020004901A,NDC,636,RC,J9041,HCPCS,,outpatient,2.5,ML,965.03,820.28,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",44.79,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44.79,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",44.79,3783,,facility
Renflexis,00006430502,NDC,636,RC,Q5104,HCPCS,,outpatient,100,ML,224.26,190.62,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,23.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,115.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,29.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.58,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39.58,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23.59,3783,,facility
Kyprolis,76075010101,NDC,636,RC,J9047,HCPCS,,outpatient,60,ML,1586.85,1348.82,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,47.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,58.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,230.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,58.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41.11,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41.11,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41.11,3783,,facility
Empliciti,00003229111,NDC,636,RC,J9176,HCPCS,,outpatient,300,ML,1488.06,1264.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.86,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.86,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.83,3783,,facility
Lupron Depot,00074334603,NDC,636,RC,J9217,HCPCS,,outpatient,22.5,ML,320.1,272.09,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,145.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,179.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,708.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,179.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,200.73,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,200.73,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.16,3783,,facility
Xgeva,55513073001,NDC,636,RC,J0897,HCPCS,,outpatient,120,ML,1634.58,1389.39,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,25.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,122.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,30.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.21,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21.21,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.21,3783,,facility
Irinotecan Hydrochloride,63323019355A,NDC,636,RC,J9206,HCPCS,,outpatient,100,ML,5.22,4.44,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Rituxan,50242005121A,NDC,636,RC,J9312,HCPCS,,outpatient,100,ML,289.16,245.79,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,63.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,78.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,310.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,78.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,85.63,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,85.63,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,74.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,63.55,3783,,facility
Cortrosyn,00548590000,NDC,250,RC,J0834,HCPCS,,inpatient,0.25,ML,19.33,16.43,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Erbitux,66733095823A,NDC,636,RC,J9055,HCPCS,,outpatient,200,ML,847.28,720.19,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,68.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,84.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,333.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,84.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,67.62,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,67.62,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,67.62,3783,,facility
Ixempra,70020191101A,NDC,636,RC,J9207,HCPCS,,outpatient,45,ML,2742.81,2331.39,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,118.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,146.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,580.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,146.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,114.19,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,114.19,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,139.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,114.19,3783,,facility
Premarin Vaginal,00046087221,NDC,636,RC,J1410,HCPCS,,outpatient,1,EA,306.47,260.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,333,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,411.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1625.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,411.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,341.5,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,306.47,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.47,3783,,facility
DAPTOmycin,25021017415A,NDC,636,RC,J0878,HCPCS,,outpatient,500,ML,15.08,12.82,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Argatroban,00143967401A,NDC,636,RC,J0883,HCPCS,,outpatient,250000,GM,200.86,170.73,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,0.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,0.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,0.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1.24,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1.24,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.52,3783,,facility
Ruxience,00069023801,NDC,636,RC,Q5119,HCPCS,,outpatient,100,ML,239.03,203.18,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,11.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,56.37,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,56.37,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.28,3783,,facility
Actemra,50242013701,NDC,636,RC,J3262,HCPCS,,outpatient,400,ML,2305.8,1959.93,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.73,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.73,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.77,3783,,facility
Phesgo,50242024501,NDC,636,RC,J9316,HCPCS,,outpatient,15,ML,7500,6375,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,51.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,64.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,64.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,71.65,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,71.65,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51.82,3783,,facility
Enbrel,58406042534,NDC,636,RC,J1438,HCPCS,,outpatient,25,ML,19.32,16.42,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,790.78,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19.32,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,19.32,3783,,facility
Havrix,58160082611,NDC,636,RC,90632,CPT,,outpatient,1440,UN  ,57.83,49.16,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Decitabine,55111055610A,NDC,636,RC,J0894,HCPCS,,outpatient,10,ML,30,25.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",2.88,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2.88,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",2.88,3783,,facility
Zepzelca,68727071201,NDC,636,RC,J9223,HCPCS,,outpatient,4,ML,5100.78,4335.66,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,179.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,221.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,874.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,221.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,180.23,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,180.23,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,210.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,179.16,3783,,facility
Retacrit,00069130801,NDC,636,RC,Q5106,HCPCS,,outpatient,10000,UN  ,86.66,73.66,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.13,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.13,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.43,3783,,facility
Reblozyl,59572071101,NDC,636,RC,J0896,HCPCS,,outpatient,25,ML,2845.03,2418.28,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,36.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,177.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,44.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37.4,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37.4,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36.35,3783,,facility
Dexferrum,00517023410,NDC,636,RC,J1750,HCPCS,,outpatient,100,ML,23.93,20.34,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,15.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,75.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,18.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.83,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.83,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.37,3783,,facility
Kadcyla,50242008701,NDC,636,RC,J9354,HCPCS,,outpatient,160,ML,4461.12,3791.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,35.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,175.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,44.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34.15,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34.15,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34.15,3783,,facility
Fludarabine Phosphate,63323019202A,NDC,636,RC,J9185,HCPCS,,outpatient,50,ML,142.07,120.76,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Entyvio,64764030020,NDC,636,RC,J3380,HCPCS,,outpatient,300,ML,4652.77,3954.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,18.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,88.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,22.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.29,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21.29,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.16,3783,,facility
Granix,63459091211A,NDC,636,RC,J1447,HCPCS,,outpatient,480,GM,10.32,8.77,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,0.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,0.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,0.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.45,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,0.45,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.21,3783,,facility
mitoMYcin,16729011505,NDC,636,RC,J9280,HCPCS,,outpatient,5,ML,19.74,16.78,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,22.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,27.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.66,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19.74,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19.74,3783,,facility
Reblozyl,59572077501,NDC,636,RC,J0896,HCPCS,,outpatient,75,ML,8701.21,7396.03,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,36.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,177.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,44.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37.4,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37.4,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36.35,3783,,facility
Zerbaxa,67919003001,NDC,636,RC,J0695,HCPCS,,outpatient,1.5,GM,125.22,106.44,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,9.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.64,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.64,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.64,3783,,facility
Dextrose/Heparin Sodium,00409776103,NDC,636,RC,J1644,HCPCS,,outpatient,25000,UN  ,18.05,15.34,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Desmopressin Acetate Novaplus,69918089902A,NDC,636,RC,J2597,HCPCS,,outpatient,4,GM,13.79,11.72,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",9.29,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9.29,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",9.29,3783,,facility
Faslodex,00310072010,NDC,636,RC,J9395,HCPCS,,outpatient,250,ML,27.99,23.79,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",15.65,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.65,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",15.65,3783,,facility
Actemra,50242013501,NDC,636,RC,J3262,HCPCS,,outpatient,80,ML,437.42,371.81,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.73,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.73,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.77,3783,,facility
Mvasi,55513020701,NDC,636,RC,Q5107,HCPCS,,outpatient,400,ML,697.57,592.93,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,20.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,98.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,25.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.77,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39.77,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.26,3783,,facility
Anzemet,00088120632,NDC,636,RC,Q0180,HCPCS,,outpatient,100,ML,38.11,32.39,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
Kadcyla,50242008801A,NDC,636,RC,J9354,HCPCS,,outpatient,100,ML,2786.32,2368.37,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,35.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,175.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,44.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34.15,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34.15,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34.15,3783,,facility
DOCEtaxel,00955102104A,NDC,636,RC,J9171,HCPCS,,outpatient,80,ML,21.87,18.59,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Vancomycin HCl (Premix),70594005802,NDC,250,RC,J3370,HCPCS,,inpatient,1750,ML,21.58,18.34,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Perjeta,50242014501,NDC,636,RC,J9306,HCPCS,,outpatient,420,ML,4054.35,3446.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,14.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,70.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,17.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.56,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13.56,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.56,3783,,facility
Acetaminophen,24201010024A,NDC,636,RC,J0131,HCPCS,,outpatient,1000,ML,5.61,4.77,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Stelara,57894005427,NDC,636,RC,J3358,HCPCS,,outpatient,130,ML,1129.48,960.06,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,10.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.62,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11.62,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.62,3783,,facility
Veklury,61958290201A,NDC,636,RC,J0248,HCPCS,,outpatient,100,ML,599.48,509.56,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.51,3783,,facility
Kanjinti Kit,55513016401,NDC,636,RC,Q5117,HCPCS,,outpatient,21,ML,18.01,15.31,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,43.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,54.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,213.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,54.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,47.41,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18.01,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.01,3783,,facility
HyperRAB,13533031801,NDC,636,RC,90375,CPT,,outpatient,300,UN  ,418.39,355.63,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,237.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,293.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1161.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,293.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,308.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,308.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,279.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,237.96,3783,,facility
Erbitux,66733094823,NDC,636,RC,J9055,HCPCS,,outpatient,100,ML,918.46,780.69,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,68.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,84.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,333.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,84.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,67.62,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,67.62,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,80.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,67.62,3783,,facility
Neulasta Onpro,55513019201,NDC,636,RC,J2506,HCPCS,,outpatient,6,ML,674.74,573.53,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,104.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,128.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,509.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,128.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,182.03,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,182.03,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,104.41,3783,,facility
Neulasta,55513019001,NDC,636,RC,J2506,HCPCS,,outpatient,6,ML,2206.58,1875.59,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,104.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,128.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,509.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,128.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,182.03,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,182.03,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,122.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,104.41,3783,,facility
Treanda,63459039008,NDC,636,RC,J9033,HCPCS,,outpatient,25,ML,447.47,380.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.69,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20.69,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1.74,3783,,facility
Granix,63459091015A,NDC,636,RC,J1447,HCPCS,,outpatient,300,GM,160.39,136.33,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,0.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,0.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,0.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.45,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,0.45,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,0.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.21,3783,,facility
PEMEtrexed,16729023011,NDC,636,RC,J9305,HCPCS,,outpatient,500,ML,86.33,73.38,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,76.04,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,76.04,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.05,3783,,facility
Ifosfamide,63323014210,NDC,636,RC,J9208,HCPCS,,outpatient,1,GM,2.83,2.41,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PremierPro Rx Ondansetron,23155055031A,NDC,636,RC,J2405,HCPCS,,outpatient,2,ML,0.07,0.06,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Oxaliplatin,25021023320A,NDC,636,RC,J9263,HCPCS,,outpatient,100,ML,21.95,18.66,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SandoSTATIN LAR Depot,00078081881,NDC,636,RC,J2353,HCPCS,,outpatient,20,ML,704.46,598.79,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,169.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,209.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,826.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,209.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,206.56,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,206.56,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,199.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,169.29,3783,,facility
Heparin Sodium,25021040201A,NDC,636,RC,J1644,HCPCS,,outpatient,5000,UN  ,1.03,0.88,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Linezolid,00054031950A,NDC,636,RC,J2020,HCPCS,,outpatient,100,ML,2.67,2.27,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Beleodaq,72893000201,NDC,636,RC,J9032,HCPCS,,outpatient,500,ML,1155.61,982.27,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,45.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,55.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,220.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,55.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,43.42,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,43.42,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,43.42,3783,,facility
Opdivo,00003377412,NDC,636,RC,J9299,HCPCS,,outpatient,100,ML,2938.84,2498.01,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,28.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,35.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,139.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,35.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.25,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29.25,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28.53,3783,,facility
Desferal,00078046791B,NDC,636,RC,J0895,HCPCS,,outpatient,500,ML,33.05,28.09,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Vabomere,70842012006,NDC,636,RC,J2186,HCPCS,,outpatient,2,GM,160.57,136.48,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1.84,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1.84,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1.84,3783,,facility
Potassium Chloride-Sodium Chloride,00338070434,NDC,636,RC,J3480,HCPCS,,outpatient,20,UN  ,1.51,1.28,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Nexterone,43066015010,NDC,636,RC,J0282,HCPCS,,outpatient,150,ML,31.04,26.38,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Dalvance,57970010001,NDC,636,RC,J0875,HCPCS,,outpatient,500,ML,942.3,800.96,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,16.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.89,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.89,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.25,3783,,facility
Foscavir,76310002425,NDC,636,RC,J1455,HCPCS,,outpatient,6000,ML,448.42,381.16,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",71.69,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,71.69,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",71.69,3783,,facility
fosaprepitant dimeglumine,71839010401A,NDC,636,RC,J1453,HCPCS,,outpatient,150,ML,14.65,12.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Opdivo,00003373413,NDC,636,RC,J9299,HCPCS,,outpatient,240,ML,5418.88,4606.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,28.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,35.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,139.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,35.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.25,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29.25,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28.53,3783,,facility
Jevtana,00024582411,NDC,636,RC,J9043,HCPCS,,outpatient,60,ML,8432.79,7167.87,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,196.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,242.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,957.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,242.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,191.31,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,191.31,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,230.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,191.31,3783,,facility
Vidaza,59572010201A,NDC,636,RC,J9025,HCPCS,,outpatient,100,ML,290,246.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",0.89,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,0.89,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",0.89,3783,,facility
Eligard,62935075375,NDC,636,RC,J9217,HCPCS,,outpatient,7.5,ML,93.32,79.32,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,145.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,179.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,708.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,179.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,200.73,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,93.32,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,93.32,3783,,facility
Alimta,00002764001A,NDC,636,RC,J9305,HCPCS,,outpatient,100,ML,365.11,310.34,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,76.04,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,76.04,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.05,3783,,facility
DAUNOrubicin HCl,42658002102A,NDC,636,RC,J9150,HCPCS,,outpatient,20,ML,23.25,19.76,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",41.24,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23.25,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",23.25,3783,,facility
lacosamide,67877073295A,NDC,636,RC,C9254,HCPCS,,outpatient,10,ML,1.5,1.28,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Fluorouracil,63323011710,NDC,636,RC,J9190,HCPCS,,outpatient,500,ML,1.15,0.98,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Darzalex,57894050220,NDC,636,RC,J9145,HCPCS,,outpatient,400,ML,1451.16,1233.49,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,60.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,74.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,293.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,74.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57.22,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,57.22,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57.22,3783,,facility
Meperidine HCl,00641605325,NDC,636,RC,J2175,HCPCS,,outpatient,50,ML,1.89,1.61,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Prolia,55513071001,NDC,636,RC,J0897,HCPCS,,outpatient,60,ML,796.32,676.87,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,25.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,122.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,30.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.21,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21.21,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.21,3783,,facility
Vectibix,55513095601,NDC,636,RC,J9303,HCPCS,,outpatient,400,ML,2814.73,2392.52,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,147.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,182.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,720.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,182.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,130.41,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,130.41,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,130.41,3783,,facility
Vinorelbine,25021020405A,NDC,636,RC,J9390,HCPCS,,outpatient,10,ML,16.57,14.08,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Bleomycin,71288010610A,NDC,636,RC,J9040,HCPCS,,outpatient,15,UN  ,17.74,15.08,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
DOCEtaxel,67457053102A,NDC,636,RC,J9171,HCPCS,,outpatient,20,ML,24.83,21.11,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Retacrit,00069130510,NDC,636,RC,Q5106,HCPCS,,outpatient,2000,UN  ,31.84,27.06,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.13,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.13,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.43,3783,,facility
Lupron Depot,00074366303B,NDC,636,RC,J9217,HCPCS,,outpatient,11.25,ML,2000.25,1700.21,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,145.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,179.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,708.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,179.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,200.73,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,200.73,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,170.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.16,3783,,facility
Imfinzi,00310461150,NDC,636,RC,J9173,HCPCS,,outpatient,500,ML,2901.78,2466.51,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,73.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,90.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,358.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,90.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,76.86,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,76.86,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.33,3783,,facility
Vectibix,55513095401,NDC,636,RC,J9303,HCPCS,,outpatient,20,ML,705.96,600.07,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,147.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,182.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,720.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,182.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,130.41,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,130.41,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,173.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,130.41,3783,,facility
Cathflo Activase,50242004164,NDC,636,RC,J2997,HCPCS,,outpatient,2,ML,156.4,132.94,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,79.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,98.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,389.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,98.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,87.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,87.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,79.76,3783,,facility
Actemra,50242013601,NDC,636,RC,J3262,HCPCS,,outpatient,200,ML,1093.53,929.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.73,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.73,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.77,3783,,facility
Tygacil,00008499020A,NDC,636,RC,J3243,HCPCS,,outpatient,50,ML,49.7,42.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Voriconazole,68462057330A,NDC,636,RC,J3465,HCPCS,,outpatient,200,ML,19.36,16.46,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Retacrit,00069130904,NDC,636,RC,Q5106,HCPCS,,outpatient,40000,UN  ,356.55,303.07,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.13,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.13,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.43,3783,,facility
Truxima,63459010310,NDC,636,RC,Q5115,HCPCS,,outpatient,100,ML,125.37,106.56,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,25.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,125.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,31.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,57.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25.63,3783,,facility
EPINEPHrine Auto-Injectors,49502010202A,NDC,636,RC,J0171,HCPCS,,outpatient,0.3,ML,589.13,500.76,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,3783,,facility
DOBUTamine HCl in Dextrose,00338107302,NDC,250,RC,J1250,HCPCS,,inpatient,250000,GM,6.48,5.51,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
mitoXANTRONE hcl,63323013210,NDC,636,RC,J9293,HCPCS,,outpatient,20,ML,11.14,9.47,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,26.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,128.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.4,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11.14,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.14,3783,,facility
Bendeka,63459034804,NDC,636,RC,J9034,HCPCS,,outpatient,100,ML,950.21,807.68,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,10.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19.08,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19.08,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.91,3783,,facility
Yervoy,00003232711,NDC,636,RC,J9228,HCPCS,,outpatient,50,ML,6250.96,5313.32,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,158.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,196.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,775.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,196.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,160.7,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,160.7,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,158.87,3783,,facility
Cyramza,00002767801,NDC,636,RC,J9308,HCPCS,,outpatient,500,ML,4156.83,3533.31,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,64.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,79.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,313.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,79.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,63.56,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,63.56,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,63.56,3783,,facility
Phesgo,50242026001,NDC,636,RC,J9316,HCPCS,,outpatient,10,ML,5000,4250,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,51.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,64.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,64.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,71.65,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,71.65,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51.82,3783,,facility
Cyramza,00002766901,NDC,636,RC,J9308,HCPCS,,outpatient,100,ML,831.9,707.12,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,64.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,79.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,313.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,79.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,63.56,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,63.56,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,63.56,3783,,facility
DAPTOmycin,25021017916A,NDC,636,RC,J0878,HCPCS,,outpatient,350,ML,7.13,6.06,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Premarin,00046110481,NDC,636,RC,J1410,HCPCS,,outpatient,1.25,ML,2.13,1.81,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,333,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,411.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1625.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,411.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,341.5,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2.13,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.13,3783,,facility
Dexrazoxane,55150043701A,NDC,636,RC,J1190,HCPCS,,outpatient,500,ML,228.62,194.33,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,49.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,60.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,240.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,60.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,189.84,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,189.84,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.31,3783,,facility
Keytruda,00006302602,NDC,636,RC,J9271,HCPCS,,outpatient,100,ML,4284.71,3642,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,50.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,62.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,247.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,62.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52.3,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52.3,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.77,3783,,facility
Activase,50242008527,NDC,636,RC,J2997,HCPCS,,outpatient,100,ML,8536.35,7255.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,79.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,98.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,389.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,98.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,87.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,87.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,79.76,3783,,facility
Zoladex,70720095130,NDC,636,RC,J9202,HCPCS,,outpatient,10.8,ML,406.2,345.27,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,660.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,816.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3226.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,816.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,543.16,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,406.2,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,777.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,406.2,3783,,facility
Retacrit,00069131810,NDC,636,RC,Q5106,HCPCS,,outpatient,10000,UN  ,104.86,89.13,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.13,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.13,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.43,3783,,facility
Irinotecan Hydrochloride,61703034916A,NDC,636,RC,J9206,HCPCS,,outpatient,40,ML,2.73,2.32,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Caffeine Citrate,63323040603,NDC,636,RC,90675,CPT,,outpatient,60,ML,0.95,0.81,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,271.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,335.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1326.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,335.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,341.95,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,0.95,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.95,3783,,facility
Etoposide,00378326694,NDC,636,RC,J8560,HCPCS,,outpatient,50,ML,44.81,38.09,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,73.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,91.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,360.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,91.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,75.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44.81,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,86.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44.81,3783,,facility
Tysabri,64406000801A,NDC,636,RC,J2323,HCPCS,,outpatient,300,ML,990.47,841.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,20.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,101.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,25.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23.25,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23.25,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.83,3783,,facility
Premarin,00046110281,NDC,636,RC,J1410,HCPCS,,outpatient,0.625,ML,3.24,2.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,333,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,411.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1625.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,411.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,341.5,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.24,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,391.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.24,3783,,facility
vinCRIStine Sulfate,61703030916,NDC,636,RC,J9370,HCPCS,,outpatient,2,ML,20.04,17.03,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Gazyva,50242007001,NDC,636,RC,J9301,HCPCS,,outpatient,1000,ML,4278.71,3636.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,69.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,85.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,338.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,85.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64.11,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,64.11,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64.11,3783,,facility
Simplist Adenosine,63323065189A,NDC,636,RC,J0153,HCPCS,,outpatient,6,ML,34.88,29.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Opdivo,00003377211,NDC,636,RC,J9299,HCPCS,,outpatient,40,ML,1175.54,999.21,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,28.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,35.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,139.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,35.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.25,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29.25,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28.53,3783,,facility
Alimta,00002762301A,NDC,636,RC,J9305,HCPCS,,outpatient,500,ML,1731.47,1471.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,76.04,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,76.04,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.05,3783,,facility
Yervoy,00003232822,NDC,636,RC,J9228,HCPCS,,outpatient,200,ML,24059.29,20450.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,158.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,196.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,775.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,196.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,160.7,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,160.7,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,158.87,3783,,facility
Avastin,50242006001,NDC,636,RC,J9035,HCPCS,,outpatient,100,ML,369.46,314.04,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,62.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,77.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,305.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,77.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,67.86,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,67.86,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.59,3783,,facility
Cladribine,63323014010,NDC,636,RC,J9065,HCPCS,,outpatient,10,ML,421.06,357.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.08,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.08,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.31,3783,,facility
Gemcitabine,63323010213,NDC,636,RC,J9201,HCPCS,,outpatient,200,ML,3.81,3.24,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Proleukin,76310002201A,NDC,636,RC,J9015,HCPCS,,outpatient,22,UN  ,1045.81,888.94,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2838.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3505.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13856.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3505.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3795.26,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1045.81,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3338.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1045.81,13856.31,,facility
Tecentriq,50242091801,NDC,636,RC,J9022,HCPCS,,outpatient,840,ML,4784.89,4067.16,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,79.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,98.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,389.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,98.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,79.58,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,79.58,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,79.58,3783,,facility
Retacrit,00069130610,NDC,636,RC,Q5106,HCPCS,,outpatient,3000,UN  ,26.74,22.73,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.13,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.13,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.43,3783,,facility
Herceptin Hylecta,50242007701,NDC,636,RC,J9356,HCPCS,,outpatient,5,ML,1657.37,1408.76,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,51.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,64.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,253.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,64.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,71.49,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,71.49,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51.91,3783,,facility
Remicade,57894003001,NDC,636,RC,J1745,HCPCS,,outpatient,100,ML,203.05,172.59,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,27.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,34.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,134.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,34.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37.88,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37.88,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27.56,3783,,facility
RhoGAM Ultra-Filtered Plus,00562780501,NDC,636,RC,J2790,HCPCS,,outpatient,1500,UN  ,118,100.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Nabi-HB,69800420201,NDC,636,RC,90371,CPT,,outpatient,1,ML,494.56,420.38,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,117.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,144.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,571.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,144.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135.59,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135.59,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,117.16,3783,,facility
RabAvert,50632001001A,NDC,636,RC,90675,CPT,,outpatient,2.5,UN  ,334.71,284.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,271.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,335.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1326.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,335.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,341.95,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,334.71,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,319.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,271.79,3783,,facility
Corvert,00009379401,NDC,636,RC,J1742,HCPCS,,outpatient,0.1,ML,429.89,365.41,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,168.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,208.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,823.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,208.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,316.2,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,316.2,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,198.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,168.73,3783,,facility
165 MINUTES IN PACU,"""01310165""",CDM,710,RC,,,,outpatient,,,1769,1503.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
DRAIN NASOBILIARY 5FR,"""01404362""",CDM,272,RC,,,,outpatient,,,526,447.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SPLINT ADULT LEFT FOREARM,"""01404278""",CDM,272,RC,,,,outpatient,,,49,41.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"CATH, TRANSLUMIN NON-LASER",C1725,HCPCS,278,RC,,,,outpatient,,,538,457.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,2375,2018.75,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
THERASKIN,Q4121,HCPCS,278,RC,,,,outpatient,,,103,87.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,472.8,472.8,472.8,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
"CATH, TRANSLUMIN NON-LASER",C1725,HCPCS,278,RC,,,,outpatient,,,563,478.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
AFFINITY1 SQUARE CM,Q4159,HCPCS,278,RC,,,,outpatient,,,455,386.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,250,212.5,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"DERMACELL, AWM, POROUS SQ CM",Q4122,HCPCS,278,RC,,,,outpatient,,,207,175.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
"DERMACELL, AWM, POROUS SQ CM",Q4122,HCPCS,278,RC,,,,outpatient,,,375,318.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
PURAPLY AM 1 SQ CM,Q4196,HCPCS,278,RC,,,,outpatient,,,136,115.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,895.84,895.84,1293.6,24,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
GRAFIX STRAVIX PRIME PL SQCM,Q4133,HCPCS,278,RC,,,,outpatient,,,253,215.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
THERASKIN,Q4121,HCPCS,278,RC,,,,outpatient,,,371,315.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,472.8,472.8,472.8,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
"DERMACELL, AWM, POROUS SQ CM",Q4122,HCPCS,278,RC,,,,outpatient,,,74,62.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
THERASKIN,Q4121,HCPCS,278,RC,,,,outpatient,,,58,49.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,472.8,472.8,472.8,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
THERASKIN,Q4121,HCPCS,278,RC,,,,outpatient,,,197,167.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,472.8,472.8,472.8,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
"DERMACELL, AWM, POROUS SQ CM",Q4122,HCPCS,278,RC,,,,outpatient,,,563,478.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
"DERMACELL, AWM, POROUS SQ CM",Q4122,HCPCS,278,RC,,,,outpatient,,,115,97.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
THERASKIN,Q4121,HCPCS,278,RC,,,,outpatient,,,37,31.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,472.8,472.8,472.8,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
THERASKIN,Q4121,HCPCS,278,RC,,,,outpatient,,,41,34.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,472.8,472.8,472.8,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
BLADE MILLER BRITE PRO SZ 1,"""02712922""",CDM,270,RC,,,,outpatient,,,33,28.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,630,535.5,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
INFLUX PROTEIOS GF X-SMALL,"""04944465""",CDM,278,RC,,,,outpatient,,,1638,1392.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PURAPLY AM 1 SQ CM,Q4196,HCPCS,278,RC,,,,outpatient,,,292,248.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,895.84,895.84,1293.6,24,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
CATH BALL ULTRAVERSE 014 3X220,"""02713934""",CDM,270,RC,,,,outpatient,,,1023,869.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1440,1224,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SCREW REM SYS BROKE & STRIP V2,"""02712903""",CDM,270,RC,,,,outpatient,,,4410,3748.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,813,691.05,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,151,128.35,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PURAPLY AM 1 SQ CM,Q4196,HCPCS,278,RC,,,,outpatient,,,258,219.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,895.84,895.84,1293.6,24,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
KIT PLEUREX CHEST 50-7000,"""02713945""",CDM,270,RC,,,,outpatient,,,1792,1523.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,3283,2790.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Aveeno Bath Treatment,08137003640,NDC,250,RC,,,,inpatient,1,EA,5.5,4.68,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Aveeno Baby Soothing Bath Treatment,08137003662A,NDC,250,RC,,,,inpatient,1,EA,2.01,1.71,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
Doxy 100,63323013002C,NDC,636,RC,91300,CPT,,outpatient,10,ML,20,17,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",0.01,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,0.01,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",0.01,3783,,facility
SEIZURES WITH MCC,100,MS-DRG,120,RC,,,,inpatient,,,,,29886.71,,,,,,,case rate,,21469.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21469.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32558.6,,,,,,,case rate,,34340.86,,,,,,,case rate,,28910.8,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21469.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20396.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21469.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21469.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21469.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22543.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21469.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21469.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21469.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22543.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21469.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21469.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21469.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31137.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31137.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21469.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21469.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,34340.86,,facility
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,120,RC,,,,inpatient,,,,,47701.61,,,,,,,case rate,,34778.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34778.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,53256.5,,,,,,,case rate,,56171.78,,,,,,,case rate,,47289.75,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,34778.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33039.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34778.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34778.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34778.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36517.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34778.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34778.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34778.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36517.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34778.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34778.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34778.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50931.42,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50931.42,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34778.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34778.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,56171.78,,facility
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,120,RC,,,,inpatient,,,,,16255.31,,,,,,,case rate,,11825.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11825.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17434.66,,,,,,,case rate,,18389.04,,,,,,,case rate,,15481.31,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11825.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11234.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11825.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11825.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11825.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12417.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11825.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11825.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11825.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12417.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11825.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11825.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11825.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16673.49,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16673.49,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11825.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11825.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18389.04,,facility
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,120,RC,,,,inpatient,,,,,24965.55,,,,,,,case rate,,18812.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18812.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26846.68,,,,,,,case rate,,28316.27,,,,,,,case rate,,23838.83,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18812.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17871.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18812.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18812.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18812.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19753.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18812.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18812.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18812.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19753.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18812.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18812.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18812.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25674.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25674.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18812.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18812.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28316.27,,facility
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,120,RC,,,,inpatient,,,,,22730.03,,,,,,,case rate,,15483.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15483.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22824.69,,,,,,,case rate,,24074.12,,,,,,,case rate,,20267.45,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15483.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14709.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15483.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15483.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15483.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16257.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15483.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15483.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15483.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16257.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15483.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15483.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15483.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21828.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21828.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15483.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15483.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24074.12,,facility
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,120,RC,,,,inpatient,,,,,17992.54,,,,,,,case rate,,13673.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13673.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19004.7,,,,,,,case rate,,20045.02,,,,,,,case rate,,16875.45,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13673.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12989.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13673.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13673.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13673.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14357.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13673.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13673.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13673.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14357.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13673.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13673.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13673.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18174.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18174.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13673.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13673.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20045.02,,facility
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,120,RC,,,,inpatient,,,,,24471.78,,,,,,,case rate,,16705.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16705.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27948.66,,,,,,,case rate,,29478.58,,,,,,,case rate,,24817.35,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16705.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15870.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16705.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16705.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16705.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17541.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16705.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16705.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16705.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17541.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16705.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16705.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16705.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26728.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26728.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16705.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16705.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29478.58,,facility
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,120,RC,,,,inpatient,,,,,23047.67,,,,,,,case rate,,17114.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17114.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25692.14,,,,,,,case rate,,27098.54,,,,,,,case rate,,22813.65,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17114.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16258.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17114.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17114.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17114.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17970.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17114.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17114.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17114.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17970.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17114.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17114.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17114.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24570.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24570.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17114.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17114.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27098.54,,facility
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,120,RC,,,,inpatient,,,,,26808.16,,,,,,,case rate,,19392.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19392.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29201.74,,,,,,,case rate,,30800.25,,,,,,,case rate,,25930.03,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19392.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18422.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19392.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19392.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19392.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20362.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19392.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19392.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19392.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20362.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19392.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19392.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19392.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27926.84,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27926.84,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19392.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19392.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30800.25,,facility
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,120,RC,,,,inpatient,,,,,36411.11,,,,,,,case rate,,27485.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27485.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39415.2,,,,,,,case rate,,41572.8,,,,,,,case rate,,34999.2,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,27485.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26111.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27485.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27485.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27485.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28860.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27485.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27485.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27485.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28860.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27485.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27485.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27485.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37694.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37694.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27485.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27485.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,41572.8,,facility
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,120,RC,,,,inpatient,,,,,67512.67,,,,,,,case rate,,47003.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,47003.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,70664.88,,,,,,,case rate,,74533.1,,,,,,,case rate,,62747.73,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,47003.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44653.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47003.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47003.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47003.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,49353.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,47003.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47003.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,47003.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49353.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,47003.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,47003.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47003.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,67579.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,67579.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47003.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47003.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,74533.1,,facility
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,120,RC,,,,inpatient,,,,,10122.31,,,,,,,case rate,,7775.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7775.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10807.98,,,,,,,case rate,,11399.61,,,,,,,case rate,,9597.07,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7775.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7387.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7775.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7775.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7775.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8164.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7775.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7775.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7775.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8164.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7775.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7775.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7775.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10336.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10336.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7775.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7775.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,11399.61,,facility
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,120,RC,,,,inpatient,,,,,75319.68,,,,,,,case rate,,60802.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,60802.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73253.15,,,,,,,case rate,,77263.05,,,,,,,case rate,,65046.01,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,60802.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,57762.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60802.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60802.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60802.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,63843.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,60802.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60802.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,60802.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,63843.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,60802.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60802.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60802.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,70055.04,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,70055.04,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,60802.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60802.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,77263.05,,facility
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,120,RC,,,,inpatient,,,,,86400.93,,,,,,,case rate,,65104.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,65104.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,99774.65,,,,,,,case rate,,105236.35,,,,,,,case rate,,88596.1,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,65104.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,61849.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65104.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65104.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65104.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,68359.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,65104.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65104.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,65104.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,68359.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,65104.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,65104.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65104.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,95418.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,95418.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,65104.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65104.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,105236.35,,facility
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,120,RC,,,,inpatient,,,,,61230.64,,,,,,,case rate,,45487.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,45487.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,64228.71,,,,,,,case rate,,67744.61,,,,,,,case rate,,57032.65,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,45487.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,43213.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45487.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45487.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45487.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47762,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,45487.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45487.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,45487.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,47762,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,45487.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45487.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45487.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,61424.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,61424.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45487.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45487.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,67744.61,,facility
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,120,RC,,,,inpatient,,,,,52729.65,,,,,,,case rate,,37634.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37634.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55455.54,,,,,,,case rate,,58491.2,,,,,,,case rate,,49242.42,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,37634.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,35753.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37634.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37634.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37634.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,39516.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,37634.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37634.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37634.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39516.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,37634.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37634.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37634.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53034.45,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,53034.45,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37634.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37634.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,58491.2,,facility
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,120,RC,,,,inpatient,,,,,14725.82,,,,,,,case rate,,11483.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11483.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15422.84,,,,,,,case rate,,16267.09,,,,,,,case rate,,13694.9,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11483.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10909.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11483.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11483.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11483.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12057.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11483.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11483.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11483.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12057.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11483.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11483.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11483.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14749.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14749.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11483.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11483.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16267.09,,facility
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,120,RC,,,,inpatient,,,,,14545.17,,,,,,,case rate,,10941.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10941.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15626.48,,,,,,,case rate,,16481.88,,,,,,,case rate,,13875.72,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10941.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10394.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10941.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10941.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10941.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11488.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10941.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10941.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10941.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11488.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10941.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10941.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10941.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14944.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14944.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10941.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10941.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16481.88,,facility
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,120,RC,,,,inpatient,,,,,17197.69,,,,,,,case rate,,12903,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12903,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18715.65,,,,,,,case rate,,19740.15,,,,,,,case rate,,16618.79,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12903,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12257.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12903,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12903,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12903,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13548.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12903,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12903,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12903,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13548.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12903,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12903,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12903,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17898.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17898.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12903,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12903,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,19740.15,,facility
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,120,RC,,,,inpatient,,,,,28060.66,,,,,,,case rate,,21225,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21225,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30816.12,,,,,,,case rate,,32503,,,,,,,case rate,,27363.54,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21225,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20163.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21225,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21225,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21225,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22286.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21225,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21225,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21225,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22286.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21225,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21225,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21225,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29470.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29470.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21225,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21225,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32503,,facility
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,120,RC,,,,inpatient,,,,,29177.66,,,,,,,case rate,,20056.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20056.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35008.91,,,,,,,case rate,,36925.31,,,,,,,case rate,,31086.58,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20056.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19053.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20056.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20056.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20056.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21059.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20056.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20056.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20056.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21059.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20056.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20056.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20056.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33480.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33480.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20056.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20056.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36925.31,,facility
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,120,RC,,,,inpatient,,,,,33501.17,,,,,,,case rate,,24270.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24270.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38084.94,,,,,,,case rate,,40169.72,,,,,,,case rate,,33817.98,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,24270.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23056.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24270.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24270.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24270.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25483.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24270.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24270.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24270.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25483.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24270.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24270.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24270.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36422.21,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36422.21,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24270.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24270.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,40169.72,,facility
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,120,RC,,,,inpatient,,,,,15100.67,,,,,,,case rate,,14047.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14047.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18303.43,,,,,,,case rate,,19305.37,,,,,,,case rate,,16252.75,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14047.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13345.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14047.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14047.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14047.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14749.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14047.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14047.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14047.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14749.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14047.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14047.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14047.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17504.34,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17504.34,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14047.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14047.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,19305.37,,facility
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,120,RC,,,,inpatient,,,,,21366.14,,,,,,,case rate,,16421.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16421.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23356.79,,,,,,,case rate,,24635.35,,,,,,,case rate,,20739.94,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16421.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15600.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16421.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16421.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16421.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17242.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16421.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16421.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16421.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17242.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16421.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16421.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16421.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22337.07,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22337.07,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16421.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16421.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24635.35,,facility
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,120,RC,,,,inpatient,,,,,28077.22,,,,,,,case rate,,19624.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19624.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29950.63,,,,,,,case rate,,31590.13,,,,,,,case rate,,26595.02,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19624.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18643.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19624.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19624.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19624.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20605.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19624.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19624.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19624.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20605.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19624.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19624.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19624.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28643.03,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28643.03,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19624.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19624.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,31590.13,,facility
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,120,RC,,,,inpatient,,,,,29924.34,,,,,,,case rate,,20095.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20095.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36273.48,,,,,,,case rate,,38259.1,,,,,,,case rate,,32209.47,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20095.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19090.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20095.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20095.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20095.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21100.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20095.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20095.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20095.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21100.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20095.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20095.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20095.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34689.84,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34689.84,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20095.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20095.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,38259.1,,facility
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,120,RC,,,,inpatient,,,,,70445.19,,,,,,,case rate,,50167.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,50167.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73934.7,,,,,,,case rate,,77981.91,,,,,,,case rate,,65651.21,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,50167.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47658.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50167.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50167.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50167.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52675.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50167.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50167.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,50167.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,52675.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50167.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50167.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50167.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,70706.84,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,70706.84,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50167.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50167.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,77981.91,,facility
LIVER TRANSPLANT WITHOUT MCC,006,MS-DRG,120,RC,,,,inpatient,,,,,72999.86,,,,,,,case rate,,50732.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,50732.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,79436.41,,,,,,,case rate,,83784.78,,,,,,,case rate,,70536.51,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,50732.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48196.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50732.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50732.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50732.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,53269.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50732.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50732.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,50732.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,53269.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50732.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50732.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50732.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,50732.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50732.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,83784.78,,facility
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,120,RC,,,,inpatient,,,,,69386.9,,,,,,,case rate,,49050.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49050.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,77411.45,,,,,,,case rate,,81648.98,,,,,,,case rate,,68738.43,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,49050.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,46598.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49050.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49050.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49050.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51503.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49050.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49050.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49050.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,51503.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49050.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49050.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49050.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,74031.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,74031.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49050.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49050.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,81648.98,,facility
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,120,RC,,,,inpatient,,,,,19412.13,,,,,,,case rate,,16473.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16473.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22335.28,,,,,,,case rate,,23557.92,,,,,,,case rate,,19832.88,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16473.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15650.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16473.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16473.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16473.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17297.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16473.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16473.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16473.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17297.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16473.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16473.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16473.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21360.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21360.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16473.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16473.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23557.92,,facility
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,120,RC,,,,inpatient,,,,,11820.4,,,,,,,case rate,,9727.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9727.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13649.16,,,,,,,case rate,,14396.31,,,,,,,case rate,,12119.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9727.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9241.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9727.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9727.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9727.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10214.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9727.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9727.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9727.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10214.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9727.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9727.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9727.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13053.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13053.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9727.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9727.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14396.31,,facility
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,120,RC,,,,inpatient,,,,,19744.83,,,,,,,case rate,,14597.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14597.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21630.73,,,,,,,case rate,,22814.81,,,,,,,case rate,,19207.27,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14597.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13868.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14597.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14597.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14597.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15327.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14597.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14597.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14597.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15327.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14597.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14597.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14597.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20686.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20686.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14597.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14597.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22814.81,,facility
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,120,RC,,,,inpatient,,,,,125559.39,,,,,,,case rate,,98120.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,98120.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,98120.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,93214.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,98120.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,98120.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,98120.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,103026.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,98120.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,98120.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,98120.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,103026.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,98120.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,98120.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,98120.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,98120.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,98120.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,125559.39,,facility
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,120,RC,,,,inpatient,,,,,14837.22,,,,,,,case rate,,11398.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11398.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16347.45,,,,,,,case rate,,17242.32,,,,,,,case rate,,14515.92,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11398.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10828.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11398.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11398.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11398.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11968.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11398.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11398.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11398.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11968.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11398.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11398.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11398.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15633.75,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15633.75,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11398.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11398.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17242.32,,facility
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,120,RC,,,,inpatient,,,,,39942.78,,,,,,,case rate,,29062.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29062.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39487.46,,,,,,,case rate,,41649.02,,,,,,,case rate,,35063.37,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,29062.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27609.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29062.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29062.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29062.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30515.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29062.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29062.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29062.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30515.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29062.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29062.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29062.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37763.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37763.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29062.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29062.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,41649.02,,facility
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,120,RC,,,,inpatient,,,,,41120,,,,,,,case rate,,29808.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29808.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42584.84,,,,,,,case rate,,44915.95,,,,,,,case rate,,37813.72,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,29808.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28317.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29808.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29808.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29808.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31298.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29808.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29808.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29808.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31298.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29808.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29808.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29808.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40725.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40725.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29808.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29808.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,44915.95,,facility
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,120,RC,,,,inpatient,,,,,21095.17,,,,,,,case rate,,16297.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16297.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22931.43,,,,,,,case rate,,24186.71,,,,,,,case rate,,20362.24,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16297.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15482.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16297.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16297.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16297.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17112.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16297.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16297.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16297.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17112.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16297.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16297.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16297.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21930.29,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21930.29,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16297.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16297.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24186.71,,facility
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,120,RC,,,,inpatient,,,,,17428.02,,,,,,,case rate,,12979.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12979.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19696.1,,,,,,,case rate,,20774.27,,,,,,,case rate,,17489.39,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12979.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12330.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12979.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12979.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12979.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13628.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12979.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12979.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12979.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13628.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12979.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12979.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12979.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18836.21,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18836.21,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12979.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12979.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20774.27,,facility
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,120,RC,,,,inpatient,,,,,43025.84,,,,,,,case rate,,33214.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33214.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44680.41,,,,,,,case rate,,47126.23,,,,,,,case rate,,39674.51,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,33214.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31553.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33214.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33214.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33214.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,34875.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33214.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33214.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33214.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34875.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33214.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33214.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33214.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42729.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42729.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33214.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33214.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,47126.23,,facility
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,120,RC,,,,inpatient,,,,,8823.15,,,,,,,case rate,,7282.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7282.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10316.93,,,,,,,case rate,,10881.68,,,,,,,case rate,,9161.04,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7282.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6918.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7282.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7282.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7282.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7646.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7282.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7282.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7282.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7646.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7282.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7282.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7282.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9866.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9866.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7282.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7282.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,10881.68,,facility
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,120,RC,,,,inpatient,,,,,13518.49,,,,,,,case rate,,10100.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10100.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14498.22,,,,,,,case rate,,15291.86,,,,,,,case rate,,12873.87,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10100.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9595.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10100.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10100.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10100.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10605.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10100.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10100.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10100.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10605.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10100.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10100.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10100.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13865.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13865.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10100.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10100.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15291.86,,facility
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,120,RC,,,,inpatient,,,,,47877.74,,,,,,,case rate,,35385.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35385.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52808.16,,,,,,,case rate,,55698.89,,,,,,,case rate,,46891.64,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,35385.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33615.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35385.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35385.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35385.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37154.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35385.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35385.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35385.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37154.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35385.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35385.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35385.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50502.64,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50502.64,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35385.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35385.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,55698.89,,facility
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,120,RC,,,,inpatient,,,,,7825.07,,,,,,,case rate,,6147.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6147.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8405.29,,,,,,,case rate,,8865.4,,,,,,,case rate,,7463.58,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,6147.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5839.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6147.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6147.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6147.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6454.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6147.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6147.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6147.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6454.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6147.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6147.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6147.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8038.33,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8038.33,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6147.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6147.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,8865.4,,facility
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,120,RC,,,,inpatient,,,,,12905.79,,,,,,,case rate,,9401.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9401.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15352.22,,,,,,,case rate,,16192.61,,,,,,,case rate,,13632.19,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9401.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8931.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9401.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9401.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9401.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9871.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9401.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9401.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9401.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9871.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9401.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9401.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9401.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14681.97,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14681.97,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9401.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9401.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16192.61,,facility
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,120,RC,,,,inpatient,,,,,51562.96,,,,,,,case rate,,38699.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,38699.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,57255.5,,,,,,,case rate,,60389.69,,,,,,,case rate,,50840.71,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,38699.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36764.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38699.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38699.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38699.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,40634.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,38699.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38699.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,38699.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40634.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,38699.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,38699.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38699.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,54755.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,54755.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38699.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38699.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,60389.69,,facility
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,120,RC,,,,inpatient,,,,,14903.46,,,,,,,case rate,,10765.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10765.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16381.94,,,,,,,case rate,,17278.7,,,,,,,case rate,,14546.54,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10765.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10227.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10765.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10765.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10765.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11304.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10765.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10765.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10765.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11304.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10765.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10765.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10765.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15666.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15666.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10765.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10765.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17278.7,,facility
HYPERTENSION WITH MCC,304,MS-DRG,120,RC,,,,inpatient,,,,,17685.44,,,,,,,case rate,,13376.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13376.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18870.03,,,,,,,case rate,,19902.98,,,,,,,case rate,,16755.87,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13376.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12707.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13376.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13376.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13376.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14045.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13376.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13376.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13376.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14045.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13376.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13376.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13376.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18046.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18046.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13376.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13376.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,19902.98,,facility
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,120,RC,,,,inpatient,,,,,46423.53,,,,,,,case rate,,34726.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34726.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,51794.86,,,,,,,case rate,,54630.12,,,,,,,case rate,,45991.87,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,34726.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32989.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34726.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34726.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34726.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36462.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34726.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34726.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34726.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36462.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34726.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34726.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34726.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49533.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49533.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34726.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34726.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,54630.12,,facility
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,120,RC,,,,inpatient,,,,,53962.57,,,,,,,case rate,,39622.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39622.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,59728.81,,,,,,,case rate,,62998.38,,,,,,,case rate,,53036.91,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,39622.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37641.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39622.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39622.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39622.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41603.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39622.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39622.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39622.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41603.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39622.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39622.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39622.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57121.15,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,57121.15,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39622.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39622.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,62998.38,,facility
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,120,RC,,,,inpatient,,,,,17509.31,,,,,,,case rate,,13270.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13270.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19328.23,,,,,,,case rate,,20386.26,,,,,,,case rate,,17162.73,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13270.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12606.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13270.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13270.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13270.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13933.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13270.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13270.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13270.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13933.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13270.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13270.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13270.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18484.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18484.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13270.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13270.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20386.26,,facility
RECTAL RESECTION WITH MCC,332,MS-DRG,120,RC,,,,inpatient,,,,,52217.81,,,,,,,case rate,,39718.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39718.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,59576.07,,,,,,,case rate,,62837.29,,,,,,,case rate,,52901.29,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,39718.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37732.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39718.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39718.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39718.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41704.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39718.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39718.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39718.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41704.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39718.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39718.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39718.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,56975.09,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,56975.09,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39718.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39718.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,62837.29,,facility
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,120,RC,,,,inpatient,,,,,424045.59,,,,,,,case rate,,304184.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,304184.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,445040.31,,,,,,,case rate,,469401.95,,,,,,,case rate,,395178.88,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,304184.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,288975.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,304184.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,304184.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,304184.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,319393.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,304184.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,304184.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,304184.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,319393.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,304184.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,304184.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,304184.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,304184.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,304184.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,469401.95,,facility
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,120,RC,,,,inpatient,,,,,61903.55,,,,,,,case rate,,45875.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,45875.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,66368.63,,,,,,,case rate,,70001.67,,,,,,,case rate,,58932.82,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,45875.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,43581.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45875.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45875.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45875.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48169.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,45875.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45875.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,45875.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,48169.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,45875.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45875.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45875.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,63471.09,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,63471.09,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45875.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45875.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,70001.67,,facility
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,120,RC,,,,inpatient,,,,,75289.57,,,,,,,case rate,,54001.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,54001.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,82103.5,,,,,,,case rate,,86597.87,,,,,,,case rate,,72904.79,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,54001.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51301.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54001.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54001.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54001.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,56701.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,54001.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54001.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,54001.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,56701.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,54001.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,54001.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54001.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,78519.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,78519.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,54001.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54001.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,86597.87,,facility
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,120,RC,,,,inpatient,,,,,66696.75,,,,,,,case rate,,45960.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,45960.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,71075.46,,,,,,,case rate,,74966.15,,,,,,,case rate,,63112.31,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,45960.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,43662.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45960.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45960.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45960.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48258.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,45960.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45960.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,45960.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,48258.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,45960.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45960.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45960.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,67972.43,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,67972.43,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45960.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45960.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,74966.15,,facility
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,120,RC,,,,inpatient,,,,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37745.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37745.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,37745.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,35858.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37745.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37745.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37745.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,39632.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,37745.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37745.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37745.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39632.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,37745.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37745.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37745.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37745.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37745.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,39632.7,,facility
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,120,RC,,,,inpatient,,,,,17795.33,,,,,,,case rate,,15143.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15143.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20229.85,,,,,,,case rate,,21337.24,,,,,,,case rate,,17963.34,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15143.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14385.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15143.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15143.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15143.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15900.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15143.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15143.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15143.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15900.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15143.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15143.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15143.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19346.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19346.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15143.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15143.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,21337.24,,facility
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,120,RC,,,,inpatient,,,,,26314.39,,,,,,,case rate,,19695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28702.48,,,,,,,case rate,,30273.66,,,,,,,case rate,,25486.71,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18711.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20680.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20680.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27449.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27449.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30273.66,,facility
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,120,RC,,,,inpatient,,,,,57962.42,,,,,,,case rate,,40986.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40986.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,66641.25,,,,,,,case rate,,70289.21,,,,,,,case rate,,59174.9,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,40986.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,38937.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40986.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40986.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40986.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,43036.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,40986.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40986.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40986.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,43036.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,40986.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40986.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40986.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,63731.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,63731.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40986.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40986.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,70289.21,,facility
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,120,RC,,,,inpatient,,,,,97357.23,,,,,,,case rate,,70215.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,70215.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,113450.08,,,,,,,case rate,,119660.38,,,,,,,case rate,,100739.36,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,70215.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,66704.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70215.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70215.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70215.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,73725.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,70215.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70215.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,70215.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,73725.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,70215.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,70215.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70215.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108497.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,108497.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,70215.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,70215.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,119660.38,,facility
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,120,RC,,,,inpatient,,,,,63070.24,,,,,,,case rate,,46014.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46014.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,60732.25,,,,,,,case rate,,64056.76,,,,,,,case rate,,53927.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,46014.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,43713.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46014.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46014.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46014.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48315.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46014.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46014.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46014.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,48315.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46014.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46014.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46014.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58080.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,58080.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46014.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46014.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,64056.76,,facility
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,120,RC,,,,inpatient,,,,,18683.52,,,,,,,case rate,,15891.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15891.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21404.1,,,,,,,case rate,,22575.76,,,,,,,case rate,,19006.02,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15891.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15097.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15891.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15891.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15891.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16686.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15891.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15891.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15891.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16686.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15891.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15891.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15891.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20469.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20469.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15891.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15891.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22575.76,,facility
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,120,RC,,,,inpatient,,,,,44273.81,,,,,,,case rate,,32041.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32041.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,48429.78,,,,,,,case rate,,51080.85,,,,,,,case rate,,43003.81,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,32041.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30439.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32041.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32041.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32041.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33643.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32041.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32041.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32041.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33643.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32041.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32041.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32041.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46315.42,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46315.42,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32041.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32041.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,51080.85,,facility
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,120,RC,,,,inpatient,,,,,15349.06,,,,,,,case rate,,11559.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11559.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17104.55,,,,,,,case rate,,18040.86,,,,,,,case rate,,15188.19,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11559.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10981.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11559.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11559.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11559.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12137.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11559.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11559.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11559.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12137.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11559.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11559.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11559.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16357.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16357.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11559.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11559.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18040.86,,facility
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,120,RC,,,,inpatient,,,,,19628.91,,,,,,,case rate,,14819.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14819.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21709.56,,,,,,,case rate,,22897.95,,,,,,,case rate,,19277.27,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14819.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14078.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14819.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14819.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14819.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15559.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14819.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14819.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14819.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15559.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14819.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14819.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14819.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20761.76,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20761.76,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14819.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14819.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22897.95,,facility
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,120,RC,,,,inpatient,,,,,58540.49,,,,,,,case rate,,42428.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42428.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,64072.69,,,,,,,case rate,,67580.05,,,,,,,case rate,,56894.12,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,42428.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,40306.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42428.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42428.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42428.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44549.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42428.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42428.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42428.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,44549.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42428.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42428.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42428.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,61275.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,61275.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42428.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42428.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,67580.05,,facility
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,120,RC,,,,inpatient,,,,,27372.69,,,,,,,case rate,,20091.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20091.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29347.9,,,,,,,case rate,,30954.41,,,,,,,case rate,,26059.82,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20091.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19086.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20091.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20091.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20091.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21095.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20091.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20091.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20091.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21095.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20091.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20091.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20091.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28066.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28066.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20091.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20091.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30954.41,,facility
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,120,RC,,,,inpatient,,,,,14481.95,,,,,,,case rate,,12117.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12117.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15426.12,,,,,,,case rate,,16270.55,,,,,,,case rate,,13697.81,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12117.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11511.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12117.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12117.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12117.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12723.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12117.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12117.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12117.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12723.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12117.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12117.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12117.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14752.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14752.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12117.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12117.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16270.55,,facility
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,120,RC,,,,inpatient,,,,,64215.85,,,,,,,case rate,,48086.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,48086.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,70269.09,,,,,,,case rate,,74115.64,,,,,,,case rate,,62396.28,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,48086.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,45682.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,48086.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,48086.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,48086.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,50490.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,48086.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,48086.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,48086.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,50490.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,48086.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48086.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,48086.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,67201.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,67201.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,48086.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,48086.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,74115.64,,facility
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,120,RC,,,,inpatient,,,,,18274.05,,,,,,,case rate,,15061.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15061.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20696.26,,,,,,,case rate,,21829.18,,,,,,,case rate,,18377.5,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15061.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14308.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15061.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15061.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15061.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15814.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15061.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15061.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15061.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15814.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15061.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15061.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15061.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19792.7,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19792.7,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15061.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15061.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,21829.18,,facility
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,120,RC,,,,inpatient,,,,,11052.65,,,,,,,case rate,,8252.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8252.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12259.77,,,,,,,case rate,,12930.87,,,,,,,case rate,,10886.21,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8252.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7840.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8252.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8252.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8252.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8665.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8252.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8252.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8252.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8665.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8252.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8252.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8252.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11724.53,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11724.53,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8252.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8252.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12930.87,,facility
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,120,RC,,,,inpatient,,,,,34372.8,,,,,,,case rate,,24191.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24191.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34279.73,,,,,,,case rate,,36156.21,,,,,,,case rate,,30439.1,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,24191.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22981.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24191.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24191.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24191.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25400.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24191.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24191.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24191.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25400.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24191.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24191.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24191.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32783.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32783.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24191.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24191.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36156.21,,facility
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,120,RC,,,,inpatient,,,,,16274.88,,,,,,,case rate,,12211.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12211.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16570.81,,,,,,,case rate,,17477.9,,,,,,,case rate,,14714.25,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12211.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11600.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12211.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12211.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12211.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12822.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12211.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12211.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12211.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12822.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12211.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12211.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12211.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15847.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15847.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12211.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12211.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17477.9,,facility
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,120,RC,,,,inpatient,,,,,23895.21,,,,,,,case rate,,17060.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17060.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25858.01,,,,,,,case rate,,27273.49,,,,,,,case rate,,22960.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17060.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16207.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17060.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17060.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17060.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17913.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17060.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17060.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17060.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17913.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17060.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17060.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17060.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24729.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24729.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17060.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17060.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27273.49,,facility
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,120,RC,,,,inpatient,,,,,12208.79,,,,,,,case rate,,9230.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9230.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13514.49,,,,,,,case rate,,14254.27,,,,,,,case rate,,12000.35,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9230.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8768.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9230.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9230.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9230.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9691.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9230.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9230.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9230.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9691.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9230.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9230.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9230.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12924.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12924.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9230.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9230.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14254.27,,facility
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,120,RC,,,,inpatient,,,,,19428.69,,,,,,,case rate,,16892.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16892.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23550.58,,,,,,,case rate,,24839.75,,,,,,,case rate,,20912.02,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16892.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16047.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16892.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16892.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16892.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17736.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16892.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16892.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16892.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17736.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16892.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16892.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16892.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22522.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22522.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16892.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16892.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24839.75,,facility
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,120,RC,,,,inpatient,,,,,36087.45,,,,,,,case rate,,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35797.21,,,,,,,case rate,,37756.76,,,,,,,case rate,,31786.57,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27010.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29853.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29853.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34234.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34234.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,37756.76,,facility
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,120,RC,,,,inpatient,,,,,61777.1,,,,,,,case rate,,46170.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46170.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,65772.47,,,,,,,case rate,,69372.88,,,,,,,case rate,,58403.46,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,46170.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,43861.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46170.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46170.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46170.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48478.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46170.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46170.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46170.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,48478.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46170.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46170.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46170.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,280816,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,62900.96,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46170.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46170.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,280816,,facility
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,120,RC,,,,inpatient,,,,,14575.28,,,,,,,case rate,,11321.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11321.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 3.00 + Fixed Amount 8669.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,7842,,,,,,,case rate,,8095,,,,,,,case rate,,14523.21,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11321.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10755.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11321.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11321.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11321.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11887.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11321.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11321.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11321.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11887.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11321.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11321.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11321.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 2.00 + Fixed Amount 11638.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Outlier Per Diem Second Dollar + Days Threshold 2.00 + Fixed Amount 13781.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,11321.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11321.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16374,,facility
PROSTATECTOMY WITH MCC,665,MS-DRG,120,RC,,,,inpatient,,,,,51689.41,,,,,,,case rate,,34305.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34305.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50732.29,,,,,,,case rate,,53509.39,,,,,,,case rate,,45048.35,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,34305.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32590.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34305.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34305.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34305.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36020.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34305.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34305.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34305.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36020.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34305.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34305.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34305.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48517.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,48517.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34305.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34305.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,53509.39,,facility
CONCUSSION WITH CC,089,MS-DRG,120,RC,,,,inpatient,,,,,16139.39,,,,,,,case rate,,12386.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12386.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18884.81,,,,,,,case rate,,19918.57,,,,,,,case rate,,16768.99,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12386.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11766.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12386.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12386.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12386.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13005.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12386.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12386.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12386.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13005.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12386.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12386.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12386.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18060.33,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18060.33,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12386.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12386.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,19918.57,,facility
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,120,RC,,,,inpatient,,,,,16643.7,,,,,,,case rate,,15175.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15175.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19878.4,,,,,,,case rate,,20966.55,,,,,,,case rate,,17651.26,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15175.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14416.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15175.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15175.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15175.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15934.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15175.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15175.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15175.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15934.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15175.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15175.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15175.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19010.54,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19010.54,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15175.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15175.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20966.55,,facility
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,120,RC,,,,inpatient,,,,,15970.79,,,,,,,case rate,,11620.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11620.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17912.57,,,,,,,case rate,,18893.11,,,,,,,case rate,,15905.68,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11620.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11039.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11620.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11620.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11620.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12202,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11620.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11620.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11620.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12202,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11620.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11620.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11620.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17130.53,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17130.53,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11620.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11620.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18893.11,,facility
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,120,RC,,,,inpatient,,,,,36552.62,,,,,,,case rate,,26968.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26968.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41014.8,,,,,,,case rate,,43259.96,,,,,,,case rate,,36419.58,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,26968.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25620.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26968.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26968.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26968.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28317.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26968.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26968.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26968.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28317.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26968.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26968.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26968.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39224.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39224.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26968.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26968.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,43259.96,,facility
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,120,RC,,,,inpatient,,,,,53953.54,,,,,,,case rate,,40982.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40982.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,59973.51,,,,,,,case rate,,63256.48,,,,,,,case rate,,53254.2,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,40982.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,38933.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40982.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40982.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40982.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,43031.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,40982.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40982.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40982.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,43031.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,40982.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40982.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40982.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57355.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,57355.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40982.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40982.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,63256.48,,facility
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,120,RC,,,,inpatient,,,,,31735.34,,,,,,,case rate,,23430.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23430.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34688.66,,,,,,,case rate,,36587.53,,,,,,,case rate,,30802.21,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23430.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22258.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23430.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23430.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23430.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24601.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23430.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23430.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23430.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24601.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23430.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23430.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23430.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33174.21,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33174.21,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23430.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23430.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36587.53,,facility
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,120,RC,,,,inpatient,,,,,34308.07,,,,,,,case rate,,24233.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24233.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36991.17,,,,,,,case rate,,39016.07,,,,,,,case rate,,32846.75,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,24233.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23021.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24233.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24233.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24233.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25445.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24233.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24233.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24233.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25445.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24233.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24233.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24233.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35376.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35376.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24233.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24233.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,39016.07,,facility
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,120,RC,,,,inpatient,,,,,52746.21,,,,,,,case rate,,39089.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39089.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,57894.36,,,,,,,case rate,,61063.51,,,,,,,case rate,,51407.99,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,39089.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37134.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39089.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39089.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39089.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41043.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39089.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39089.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39089.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41043.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39089.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39089.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39089.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55366.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55366.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39089.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39089.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,61063.51,,facility
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,120,RC,,,,inpatient,,,,,33109.77,,,,,,,case rate,,25033.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25033.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36670.92,,,,,,,case rate,,38678.29,,,,,,,case rate,,32562.38,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25033.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23781.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25033.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25033.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25033.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26284.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25033.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25033.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25033.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26284.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25033.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25033.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25033.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35069.93,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35069.93,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25033.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25033.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,38678.29,,facility
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,120,RC,,,,inpatient,,,,,21147.86,,,,,,,case rate,,15693.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15693.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24417.72,,,,,,,case rate,,25754.35,,,,,,,case rate,,21682,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15693.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14908.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15693.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15693.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15693.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16478.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15693.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15693.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15693.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16478.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15693.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15693.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15693.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23351.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23351.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15693.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15693.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25754.35,,facility
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,120,RC,,,,inpatient,,,,,43614.45,,,,,,,case rate,,32408.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32408.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,48536.53,,,,,,,case rate,,51193.44,,,,,,,case rate,,43098.6,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,32408.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30787.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32408.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32408.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32408.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,34028.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32408.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32408.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32408.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34028.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32408.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32408.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32408.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46417.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46417.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32408.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32408.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,51193.44,,facility
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,120,RC,,,,inpatient,,,,,16807.79,,,,,,,case rate,,12908.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12908.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16631.57,,,,,,,case rate,,17541.99,,,,,,,case rate,,14768.2,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12908.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12262.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12908.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12908.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12908.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13553.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12908.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12908.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12908.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13553.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12908.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12908.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12908.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15905.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15905.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12908.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12908.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17541.99,,facility
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,120,RC,,,,inpatient,,,,,38904.05,,,,,,,case rate,,28016.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28016.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42517.5,,,,,,,case rate,,44844.93,,,,,,,case rate,,37753.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,28016.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26615.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28016.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28016.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28016.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29417.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28016.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28016.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28016.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29417.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28016.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28016.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28016.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40661.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40661.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28016.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28016.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,44844.93,,facility
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,120,RC,,,,inpatient,,,,,20678.17,,,,,,,case rate,,15935.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15935.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21338.4,,,,,,,case rate,,22506.47,,,,,,,case rate,,18947.69,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15935.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15138.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15935.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15935.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15935.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16732.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15935.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15935.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15935.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16732.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15935.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15935.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15935.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20406.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20406.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15935.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15935.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22506.47,,facility
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,120,RC,,,,inpatient,,,,,10450.49,,,,,,,case rate,,7956.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7956.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11632.41,,,,,,,case rate,,12269.17,,,,,,,case rate,,10329.14,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7956.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7559.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7956.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7956.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7956.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8354.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7956.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7956.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7956.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8354.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7956.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7956.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7956.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11124.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11124.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7956.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7956.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12269.17,,facility
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,120,RC,,,,inpatient,,,,,27730.97,,,,,,,case rate,,27086.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27086.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 10230.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,11529,,,,,,,case rate,,12984,,,,,,,case rate,,25838.16,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,27086.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25732.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27086.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27086.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17858,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27086.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17858,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28441.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27086.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27086.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27086.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2122,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1804,,,,,,,per diem,,28441.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27086.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27086.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27086.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 14228.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 16055.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,27086.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27086.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28441.27,,facility
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,120,RC,,,,inpatient,,,,,34928.29,,,,,,,case rate,,25249.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25249.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37416.52,,,,,,,case rate,,39464.71,,,,,,,case rate,,33224.45,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25249.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23987.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25249.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25249.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25249.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26512.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25249.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25249.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25249.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26512.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25249.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25249.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25249.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35782.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35782.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25249.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25249.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,39464.71,,facility
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,120,RC,,,,inpatient,,,,,59398.57,,,,,,,case rate,,40868.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40868.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,65930.13,,,,,,,case rate,,69539.17,,,,,,,case rate,,58543.45,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,40868.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,38825.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40868.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40868.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40868.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,42912.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,40868.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40868.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40868.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42912.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,40868.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40868.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40868.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,63051.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,63051.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40868.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40868.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,69539.17,,facility
LUNG TRANSPLANT,007,MS-DRG,120,RC,,,,inpatient,,,,,196737.72,,,,,,,case rate,,140825.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,140825.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,201451.09,,,,,,,case rate,,212478.58,,,,,,,case rate,,178880.91,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,140825.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,133784.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,140825.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,140825.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,140825.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,147867.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,140825.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,140825.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,140825.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,147867.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,140825.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,140825.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,140825.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,140825.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,140825.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,212478.58,,facility
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,120,RC,,,,inpatient,,,,,18496.85,,,,,,,case rate,,13588.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13588.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19679.68,,,,,,,case rate,,20756.95,,,,,,,case rate,,17474.81,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13588.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12909.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13588.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13588.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13588.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14268.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13588.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13588.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13588.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14268.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13588.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13588.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13588.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18820.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18820.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13588.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13588.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20756.95,,facility
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,120,RC,,,,inpatient,,,,,43840.26,,,,,,,case rate,,31371.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31371.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46135.49,,,,,,,case rate,,48660.96,,,,,,,case rate,,40966.56,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,31371.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29803.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31371.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31371.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31371.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32940.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31371.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31371.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31371.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32940.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31371.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31371.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31371.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44121.3,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44121.3,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31371.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31371.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,48660.96,,facility
ACUTE LEUKEMIA WITH CC,835,MS-DRG,120,RC,,,,inpatient,,,,,32153.84,,,,,,,case rate,,23084.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23084.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36713.62,,,,,,,case rate,,38723.33,,,,,,,case rate,,32600.3,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23084.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21930.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23084.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23084.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23084.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24238.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23084.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23084.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23084.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24238.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23084.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23084.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23084.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35110.76,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35110.76,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23084.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23084.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,38723.33,,facility
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,120,RC,,,,inpatient,,,,,33970.86,,,,,,,case rate,,25959.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25959.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41177.39,,,,,,,case rate,,43431.45,,,,,,,case rate,,36563.96,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25959.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24661.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25959.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25959.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25959.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27257.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25959.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25959.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25959.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27257.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25959.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25959.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25959.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39379.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39379.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25959.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25959.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,43431.45,,facility
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,120,RC,,,,inpatient,,,,,16423.91,,,,,,,case rate,,11529.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11529.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17625.16,,,,,,,case rate,,18589.97,,,,,,,case rate,,15650.48,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11529.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10953.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11529.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11529.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11529.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12106.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11529.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11529.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11529.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12106.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11529.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11529.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11529.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16855.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16855.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11529.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11529.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18589.97,,facility
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,120,RC,,,,inpatient,,,,,11233.29,,,,,,,case rate,,9542.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9542.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13358.47,,,,,,,case rate,,14089.71,,,,,,,case rate,,11861.81,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9542.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9065.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9542.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9542.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9542.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10019.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9542.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9542.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9542.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10019.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9542.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9542.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9542.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12775.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12775.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9542.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9542.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14089.71,,facility
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,120,RC,,,,inpatient,,,,,15023.89,,,,,,,case rate,,12175.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12175.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 3.00 + Fixed Amount 8669.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,7842,,,,,,,case rate,,8095,,,,,,,case rate,,14702.58,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12175.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11567.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12175.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12175.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12175.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12784.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12175.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12175.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12175.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2122,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1804,,,,,,,per diem,,12784.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12175.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12175.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12175.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 2.00 + Fixed Amount 11638.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Outlier Per Diem Second Dollar + Days Threshold 2.00 + Fixed Amount 13781.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,12175.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12175.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16374,,facility
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,120,RC,,,,inpatient,,,,,14509.05,,,,,,,case rate,,10898.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10898.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15869.54,,,,,,,case rate,,16738.25,,,,,,,case rate,,14091.55,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10898.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10353.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10898.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10898.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10898.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11443.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10898.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10898.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10898.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11443.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10898.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10898.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10898.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15176.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15176.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10898.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10898.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16738.25,,facility
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,120,RC,,,,inpatient,,,,,23270.47,,,,,,,case rate,,16739.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16739.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26308,,,,,,,case rate,,27748.11,,,,,,,case rate,,23360.51,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16739.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15902.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16739.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16739.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16739.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17576.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16739.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16739.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16739.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17576.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16739.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16739.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16739.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25159.44,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25159.44,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16739.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16739.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27748.11,,facility
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,120,RC,,,,inpatient,,,,,11882.12,,,,,,,case rate,,9109.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9109.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12717.97,,,,,,,case rate,,13414.16,,,,,,,case rate,,11293.08,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9109.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8654.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9109.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9109.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9109.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9565.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9109.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9109.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9109.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9565.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9109.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9109.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9109.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12162.73,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12162.73,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9109.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9109.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13414.16,,facility
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,120,RC,,,,inpatient,,,,,28418.94,,,,,,,case rate,,20323.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20323.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29730.56,,,,,,,case rate,,31358.02,,,,,,,case rate,,26399.6,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20323.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19307.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20323.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20323.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20323.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21339.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20323.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20323.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20323.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21339.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20323.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20323.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20323.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28432.57,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28432.57,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20323.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20323.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,31358.02,,facility
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,120,RC,,,,inpatient,,,,,17217.26,,,,,,,case rate,,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20344.81,,,,,,,case rate,,21458.49,,,,,,,case rate,,18065.42,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12851.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14204.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14204.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19456.59,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19456.59,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,21458.49,,facility
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,120,RC,,,,inpatient,,,,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26644.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26644.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,26644.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25312.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26644.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26644.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26644.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27977,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26644.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26644.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26644.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27977,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26644.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26644.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26644.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26644.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26644.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27977,,facility
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,120,RC,,,,inpatient,,,,,12300.62,,,,,,,case rate,,9271.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9271.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13140.04,,,,,,,case rate,,13859.33,,,,,,,case rate,,11667.86,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9271.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8807.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9271.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9271.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9271.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9734.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9271.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9271.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9271.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9734.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9271.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9271.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9271.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12566.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12566.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9271.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9271.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13859.33,,facility
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,120,RC,,,,inpatient,,,,,15472.5,,,,,,,case rate,,12468.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12468.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17237.58,,,,,,,case rate,,18181.17,,,,,,,case rate,,15306.32,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12468.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11845.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12468.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12468.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12468.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13091.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12468.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12468.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12468.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13091.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12468.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12468.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12468.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16485.02,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16485.02,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12468.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12468.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18181.17,,facility
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,120,RC,,,,inpatient,,,,,13905.38,,,,,,,case rate,,10407.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10407.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14925.22,,,,,,,case rate,,15742.23,,,,,,,case rate,,13253.03,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10407.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9886.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10407.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10407.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10407.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10927.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10407.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10407.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10407.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10927.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10407.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10407.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10407.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14273.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14273.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10407.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10407.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15742.23,,facility
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,005,MS-DRG,120,RC,,,,inpatient,,,,,160316.07,,,,,,,case rate,,112218.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,112218.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,169978.05,,,,,,,case rate,,179282.7,,,,,,,case rate,,150934.05,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,112218.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,106607.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,112218.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,112218.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,112218.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,117829.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,112218.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,112218.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,112218.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,117829.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,112218.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,112218.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,112218.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,112218.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,112218.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,179282.7,,facility
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,120,RC,,,,inpatient,,,,,17905.23,,,,,,,case rate,,12085.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12085.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21277.64,,,,,,,case rate,,22442.38,,,,,,,case rate,,18893.73,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12085.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11481.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12085.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12085.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12085.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12690.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12085.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12085.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12085.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12690.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12085.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12085.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12085.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20348.69,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20348.69,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12085.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12085.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22442.38,,facility
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,120,RC,,,,inpatient,,,,,17394.9,,,,,,,case rate,,13476.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13476.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17741.77,,,,,,,case rate,,18712.96,,,,,,,case rate,,15754.01,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13476.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12802.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13476.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13476.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13476.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14150.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13476.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13476.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13476.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14150.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13476.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13476.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13476.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16967.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16967.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13476.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13476.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18712.96,,facility
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,120,RC,,,,inpatient,,,,,22365.73,,,,,,,case rate,,16433.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16433.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24736.32,,,,,,,case rate,,26090.4,,,,,,,case rate,,21964.91,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16433.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15612.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16433.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16433.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16433.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17255.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16433.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16433.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16433.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17255.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16433.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16433.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16433.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23656.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23656.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16433.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16433.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26090.4,,facility
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,120,RC,,,,inpatient,,,,,9742.95,,,,,,,case rate,,7437.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7437.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10540.28,,,,,,,case rate,,11117.26,,,,,,,case rate,,9359.37,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7437.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7065.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7437.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7437.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7437.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7809.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7437.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7437.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7437.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7809.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7437.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7437.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7437.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10080.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10080.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7437.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7437.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,11117.26,,facility
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,120,RC,,,,inpatient,,,,,9395.2,,,,,,,case rate,,7165.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7165.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9435.01,,,,,,,case rate,,9951.49,,,,,,,case rate,,8377.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7165.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6807.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7165.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7165.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7165.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7524,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7165.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7165.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7165.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7524,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7165.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7165.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7165.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9023.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9023.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7165.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7165.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,9951.49,,facility
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,120,RC,,,,inpatient,,,,,88580.75,,,,,,,case rate,,64080.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,64080.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,96577.09,,,,,,,case rate,,101863.75,,,,,,,case rate,,85756.79,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,64080.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,60876.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64080.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64080.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64080.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,67284.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64080.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64080.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,64080.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,67284.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64080.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64080.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64080.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,92360.7,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,92360.7,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,64080.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64080.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,101863.75,,facility
COAGULATION DISORDERS,813,MS-DRG,120,RC,,,,inpatient,,,,,23303.59,,,,,,,case rate,,17010.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17010.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25619.88,,,,,,,case rate,,27022.32,,,,,,,case rate,,22749.48,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17010.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16159.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17010.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17010.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17010.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17860.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17010.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17010.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17010.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17860.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17010.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17010.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17010.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24501.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24501.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17010.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17010.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27022.32,,facility
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,120,RC,,,,inpatient,,,,,14054.41,,,,,,,case rate,,10412.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10412.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15546.01,,,,,,,case rate,,16397.01,,,,,,,case rate,,13804.27,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10412.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9891.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10412.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10412.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10412.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10933.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10412.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10412.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10412.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10933.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10412.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10412.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10412.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14867.3,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14867.3,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10412.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10412.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16397.01,,facility
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,120,RC,,,,inpatient,,,,,14393.13,,,,,,,case rate,,10838.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10838.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15104.23,,,,,,,case rate,,15931.04,,,,,,,case rate,,13411.99,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10838.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10296.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10838.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10838.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10838.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11380.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10838.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10838.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10838.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11380.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10838.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10838.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10838.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14444.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14444.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10838.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10838.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15931.04,,facility
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,120,RC,,,,inpatient,,,,,26690.74,,,,,,,case rate,,19207.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19207.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28684.41,,,,,,,case rate,,30254.61,,,,,,,case rate,,25470.67,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19207.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18246.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19207.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19207.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19207.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20167.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19207.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19207.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19207.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20167.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19207.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19207.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19207.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27432.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27432.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19207.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19207.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30254.61,,facility
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,120,RC,,,,inpatient,,,,,51770.71,,,,,,,case rate,,37918.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37918.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55329.09,,,,,,,case rate,,58357.82,,,,,,,case rate,,49130.13,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,37918.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36022.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37918.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37918.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37918.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,39814.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,37918.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37918.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37918.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39814.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,37918.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37918.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37918.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52913.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52913.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37918.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37918.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,58357.82,,facility
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,120,RC,,,,inpatient,,,,,29684.98,,,,,,,case rate,,22157,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22157,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32330.32,,,,,,,case rate,,34100.09,,,,,,,case rate,,28708.09,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22157,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21049.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22157,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22157,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22157,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23264.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22157,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22157,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22157,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23264.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22157,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22157,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22157,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30918.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30918.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22157,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22157,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,34100.09,,facility
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,120,RC,,,,inpatient,,,,,22835.41,,,,,,,case rate,,16394.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16394.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22410.83,,,,,,,case rate,,23637.6,,,,,,,case rate,,19899.96,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16394.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15575.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16394.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16394.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16394.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17214.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16394.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16394.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16394.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17214.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16394.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16394.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16394.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21432.41,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21432.41,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16394.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16394.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23637.6,,facility
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,120,RC,,,,inpatient,,,,,29945.42,,,,,,,case rate,,22274.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22274.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32895.27,,,,,,,case rate,,34695.97,,,,,,,case rate,,29209.75,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22274.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21160.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22274.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22274.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22274.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23387.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22274.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22274.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22274.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23387.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22274.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22274.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22274.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31459.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31459.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22274.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22274.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,34695.97,,facility
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,120,RC,,,,inpatient,,,,,93250.5,,,,,,,case rate,,65575.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,65575.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,101990.11,,,,,,,case rate,,107573.08,,,,,,,case rate,,90563.35,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,65575.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,62296.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65575.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65575.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65575.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,68854.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,65575.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65575.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,65575.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,68854.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,65575.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,65575.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65575.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,97537.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,97537.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,65575.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65575.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,107573.08,,facility
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,120,RC,,,,inpatient,,,,,23788.33,,,,,,,case rate,,17453.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17453.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25371.89,,,,,,,case rate,,26760.76,,,,,,,case rate,,22529.28,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17453.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16580.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17453.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17453.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17453.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18326.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17453.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17453.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17453.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18326.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17453.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17453.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17453.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24264.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24264.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17453.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17453.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26760.76,,facility
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,120,RC,,,,inpatient,,,,,22648.74,,,,,,,case rate,,17001.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17001.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23905.32,,,,,,,case rate,,25213.9,,,,,,,case rate,,21227.01,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17001.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16151.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17001.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17001.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17001.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17851.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17001.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17001.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17001.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17851.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17001.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17001.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17001.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22861.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22861.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17001.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17001.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25213.9,,facility
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,120,RC,,,,inpatient,,,,,43086.05,,,,,,,case rate,,35272.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35272.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,43427.34,,,,,,,case rate,,45804.56,,,,,,,case rate,,38561.83,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,35272.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33508.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35272.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35272.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35272.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37035.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35272.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35272.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35272.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37035.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35272.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35272.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35272.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41531.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41531.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35272.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35272.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,45804.56,,facility
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,120,RC,,,,inpatient,,,,,69358.29,,,,,,,case rate,,51430.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,51430.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73862.44,,,,,,,case rate,,77905.69,,,,,,,case rate,,65587.04,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,51430.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48859.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51430.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51430.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51430.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,54002.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,51430.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51430.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,51430.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,54002.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,51430.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51430.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51430.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,70637.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,70637.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,51430.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51430.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,77905.69,,facility
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,120,RC,,,,inpatient,,,,,18420.07,,,,,,,case rate,,13928.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13928.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19497.39,,,,,,,case rate,,20564.68,,,,,,,case rate,,17312.94,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13928.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13231.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13928.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13928.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13928.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14624.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13928.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13928.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13928.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14624.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13928.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13928.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13928.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18646.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18646.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13928.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13928.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20564.68,,facility
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,120,RC,,,,inpatient,,,,,20974.74,,,,,,,case rate,,15244.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15244.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21681.64,,,,,,,case rate,,22868.5,,,,,,,case rate,,19252.48,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15244.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14482.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15244.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15244.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15244.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16007.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15244.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15244.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15244.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16007.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15244.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15244.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15244.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20735.06,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20735.06,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15244.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15244.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22868.5,,facility
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,120,RC,,,,inpatient,,,,,58125,,,,,,,case rate,,40286.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40286.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,53476.57,,,,,,,case rate,,56403.9,,,,,,,case rate,,47485.16,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,40286.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,38272.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40286.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40286.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40286.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,42301.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,40286.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40286.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40286.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42301.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,40286.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40286.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40286.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51141.88,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,51141.88,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40286.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40286.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,58125,,facility
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,120,RC,,,,inpatient,,,,,91960.37,,,,,,,case rate,,66182.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,66182.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,97693.86,,,,,,,case rate,,103041.65,,,,,,,case rate,,86748.43,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,66182.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,62873.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66182.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66182.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66182.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,69491.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,66182.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66182.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,66182.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,69491.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,66182.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,66182.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66182.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,93428.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,93428.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,66182.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66182.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,103041.65,,facility
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,120,RC,,,,inpatient,,,,,49207.01,,,,,,,case rate,,33351.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33351.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,54685.31,,,,,,,case rate,,57678.8,,,,,,,case rate,,48558.47,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,33351.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31684.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33351.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33351.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33351.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,35019.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33351.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33351.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33351.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35019.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33351.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33351.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33351.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52297.84,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52297.84,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33351.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33351.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,57678.8,,facility
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,120,RC,,,,inpatient,,,,,16326.06,,,,,,,case rate,,12340.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12340.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17848.52,,,,,,,case rate,,18825.55,,,,,,,case rate,,15848.8,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12340.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11723.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12340.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12340.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12340.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12957.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12340.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12340.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12340.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12957.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12340.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12340.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12340.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17069.28,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17069.28,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12340.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12340.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18825.55,,facility
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,120,RC,,,,inpatient,,,,,24684.04,,,,,,,case rate,,17477.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17477.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26209.47,,,,,,,case rate,,27644.18,,,,,,,case rate,,23273.01,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17477.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16603.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17477.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17477.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17477.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18351.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17477.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17477.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17477.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18351.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17477.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17477.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17477.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25065.21,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25065.21,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17477.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17477.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27644.18,,facility
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,120,RC,,,,inpatient,,,,,20088.06,,,,,,,case rate,,14521.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14521.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22387.83,,,,,,,case rate,,23613.35,,,,,,,case rate,,19879.55,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14521.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13794.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14521.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14521.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14521.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15247.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14521.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14521.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14521.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15247.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14521.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14521.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14521.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21410.42,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21410.42,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14521.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14521.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23613.35,,facility
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,120,RC,,,,inpatient,,,,,35629.81,,,,,,,case rate,,25358.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25358.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41863.87,,,,,,,case rate,,44155.51,,,,,,,case rate,,37173.53,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25358.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24090.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25358.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25358.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25358.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26626.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25358.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25358.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25358.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26626.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25358.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25358.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25358.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40036.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40036.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25358.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25358.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,44155.51,,facility
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,120,RC,,,,inpatient,,,,,23296.07,,,,,,,case rate,,17299.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17299.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25202.74,,,,,,,case rate,,26582.34,,,,,,,case rate,,22379.07,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17299.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16434.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17299.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17299.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17299.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18164.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17299.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17299.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17299.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18164.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17299.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17299.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17299.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24102.43,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24102.43,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17299.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17299.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26582.34,,facility
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,120,RC,,,,inpatient,,,,,10485.11,,,,,,,case rate,,8201.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8201.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10995.2,,,,,,,case rate,,11597.08,,,,,,,case rate,,9763.32,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8201.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7791.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8201.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8201.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8201.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8611.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8201.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8201.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8201.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8611.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8201.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8201.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8201.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10515.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10515.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8201.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8201.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,11597.08,,facility
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,120,RC,,,,inpatient,,,,,64121.01,,,,,,,case rate,,47377.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,47377.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,67991.22,,,,,,,case rate,,71713.08,,,,,,,case rate,,60373.62,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,47377.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,45008.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47377.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47377.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47377.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,49746.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,47377.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47377.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,47377.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49746.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,47377.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,47377.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47377.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,65022.84,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,65022.84,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47377.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,47377.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,71713.08,,facility
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,120,RC,,,,inpatient,,,,,14328.4,,,,,,,case rate,,11822.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11822.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16496.9,,,,,,,case rate,,17399.95,,,,,,,case rate,,14648.62,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11822.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11231.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11822.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11822.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11822.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12413.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11822.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11822.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11822.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12413.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11822.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11822.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11822.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15776.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15776.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11822.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11822.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17399.95,,facility
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,120,RC,,,,inpatient,,,,,40401.93,,,,,,,case rate,,30268.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30268.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44404.51,,,,,,,case rate,,46835.22,,,,,,,case rate,,39429.52,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,30268.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28755.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30268.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30268.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30268.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31782.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30268.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30268.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30268.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31782.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30268.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30268.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30268.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42465.88,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42465.88,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30268.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,1938.44,1938.44,1938.44,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,30268.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,46835.22,,facility
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,120,RC,,,,inpatient,,,,,17617.7,,,,,,,case rate,,13054.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13054.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19287.17,,,,,,,case rate,,20342.96,,,,,,,case rate,,17126.28,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13054.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12401.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13054.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13054.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13054.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13707.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13054.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13054.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13054.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13707.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13054.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13054.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13054.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18445.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18445.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13054.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,845.28,845.28,845.28,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,13054.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20342.96,,facility
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,120,RC,,,,inpatient,,,,,14170.33,,,,,,,case rate,,10620.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10620.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15386.71,,,,,,,case rate,,16228.98,,,,,,,case rate,,13662.81,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10620.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10089.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10620.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10620.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10620.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11151.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10620.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10620.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10620.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11151.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10620.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10620.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10620.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14714.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14714.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10620.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10620.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16228.98,,facility
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,120,RC,,,,inpatient,,,,,54927.53,,,,,,,case rate,,38621.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,38621.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,59495.6,,,,,,,case rate,,62752.41,,,,,,,case rate,,52829.83,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,38621.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36690.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38621.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38621.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38621.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,40552.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,38621.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38621.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,38621.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40552.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,38621.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,38621.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38621.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,56898.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,56898.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38621.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38621.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,62752.41,,facility
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,120,RC,,,,inpatient,,,,,10486.62,,,,,,,case rate,,7741.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7741.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11412.34,,,,,,,case rate,,12037.06,,,,,,,case rate,,10133.73,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7741.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7354.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7741.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7741.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7741.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8128.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7741.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7741.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7741.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8128.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7741.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7741.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7741.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10914.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10914.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7741.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7741.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12037.06,,facility
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,120,RC,,,,inpatient,,,,,63085.29,,,,,,,case rate,,49036.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49036.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,67606.92,,,,,,,case rate,,71307.75,,,,,,,case rate,,60032.38,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,49036.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,46585.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49036.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49036.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49036.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51488.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49036.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49036.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49036.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,51488.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49036.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49036.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49036.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64655.32,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,64655.32,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49036.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49036.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,71307.75,,facility
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,120,RC,,,,inpatient,,,,,14941.1,,,,,,,case rate,,11060.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11060.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15956.59,,,,,,,case rate,,16830.06,,,,,,,case rate,,14168.84,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11060.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10507.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11060.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11060.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11060.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11613.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11060.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11060.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11060.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11613.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11060.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11060.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11060.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15259.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15259.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11060.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11060.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16830.06,,facility
URINARY STONES WITH MCC,693,MS-DRG,120,RC,,,,inpatient,,,,,22135.4,,,,,,,case rate,,15050.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15050.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23259.89,,,,,,,case rate,,24533.15,,,,,,,case rate,,20653.9,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15050.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14298.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15050.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15050.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15050.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15803.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15050.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15050.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15050.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15803.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15050.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15050.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15050.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22244.41,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22244.41,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15050.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15050.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24533.15,,facility
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,120,RC,,,,inpatient,,,,,22602.08,,,,,,,case rate,,15665.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15665.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20270.91,,,,,,,case rate,,21380.54,,,,,,,case rate,,17999.8,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15665.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14882.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15665.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15665.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15665.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16448.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15665.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15665.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15665.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16448.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15665.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15665.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15665.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19385.92,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19385.92,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15665.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15665.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22602.08,,facility
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,120,RC,,,,inpatient,,,,,19007.18,,,,,,,case rate,,13162.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13162.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20379.3,,,,,,,case rate,,21494.87,,,,,,,case rate,,18096.04,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13162.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12503.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13162.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13162.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13162.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13820.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13162.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13162.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13162.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13820.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13162.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13162.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13162.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19489.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19489.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13162.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13162.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,21494.87,,facility
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,120,RC,,,,inpatient,,,,,31840.72,,,,,,,case rate,,23462.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23462.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35720.02,,,,,,,case rate,,37675.35,,,,,,,case rate,,31718.02,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23462.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22289.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23462.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23462.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23462.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24636.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23462.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23462.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23462.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24636.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23462.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23462.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23462.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34160.55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34160.55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23462.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23462.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,37675.35,,facility
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,120,RC,,,,inpatient,,,,,20069.99,,,,,,,case rate,,15056.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15056.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22377.98,,,,,,,case rate,,23602.96,,,,,,,case rate,,19870.8,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15056.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14303.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15056.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15056.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15056.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15809.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15056.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15056.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15056.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15809.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15056.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15056.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15056.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21401,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21401,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15056.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15056.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23602.96,,facility
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,120,RC,,,,inpatient,,,,,9143.8,,,,,,,case rate,,6985.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6985.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9993.4,,,,,,,case rate,,10540.44,,,,,,,case rate,,8873.76,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,6985.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6636.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6985.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6985.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6985.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7335.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6985.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6985.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6985.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7335.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6985.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6985.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6985.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9557.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9557.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6985.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6985.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,10540.44,,facility
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,120,RC,,,,inpatient,,,,,15052.49,,,,,,,case rate,,11294.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11294.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16513.33,,,,,,,case rate,,17417.27,,,,,,,case rate,,14663.21,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11294.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10729.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11294.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11294.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11294.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11859.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11294.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11294.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11294.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11859.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11294.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11294.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11294.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15792.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15792.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11294.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11294.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17417.27,,facility
SPLENIC PROCEDURES WITH CC,800,MS-DRG,120,RC,,,,inpatient,,,,,43864.35,,,,,,,case rate,,30926.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30926.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46275.09,,,,,,,case rate,,48808.2,,,,,,,case rate,,41090.52,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,30926.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29380.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30926.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30926.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30926.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32472.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30926.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30926.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30926.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32472.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30926.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30926.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30926.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44254.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44254.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30926.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30926.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,48808.2,,facility
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,120,RC,,,,inpatient,,,,,26796.12,,,,,,,case rate,,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30517.22,,,,,,,case rate,,32187.74,,,,,,,case rate,,27098.13,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19594.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21656.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21656.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29184.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29184.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32187.74,,facility
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,120,RC,,,,inpatient,,,,,21305.93,,,,,,,case rate,,15998.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15998.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24496.55,,,,,,,case rate,,25837.5,,,,,,,case rate,,21752,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15998.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15198.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15998.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15998.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15998.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16798.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15998.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15998.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15998.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16798.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15998.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15998.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15998.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23427.07,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23427.07,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15998.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15998.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25837.5,,facility
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,120,RC,,,,inpatient,,,,,16976.4,,,,,,,case rate,,12738.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12738.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18076.8,,,,,,,case rate,,19066.33,,,,,,,case rate,,16051.51,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12738.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12101.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12738.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12738.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12738.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13375.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12738.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12738.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12738.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13375.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12738.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12738.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12738.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17287.59,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17287.59,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12738.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12738.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,19066.33,,facility
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,120,RC,,,,inpatient,,,,,16475.1,,,,,,,case rate,,12179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15153.5,,,,,,,case rate,,15983.01,,,,,,,case rate,,13455.73,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11570.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12788.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12788.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14491.93,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14491.93,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16475.1,,facility
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,120,RC,,,,inpatient,,,,,9136.27,,,,,,,case rate,,7762.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7762.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10208.54,,,,,,,case rate,,10767.36,,,,,,,case rate,,9064.79,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7762.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7374.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7762.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7762.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7762.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8150.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7762.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7762.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7762.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8150.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7762.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7762.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7762.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9762.85,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9762.85,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7762.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7762.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,10767.36,,facility
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,120,RC,,,,inpatient,,,,,16237.24,,,,,,,case rate,,12237.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12237.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19681.32,,,,,,,case rate,,20758.68,,,,,,,case rate,,17476.27,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12237.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11625.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12237.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12237.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12237.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12849.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12237.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12237.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12237.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12849.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12237.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12237.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12237.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18822.07,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18822.07,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12237.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12237.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20758.68,,facility
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,120,RC,,,,inpatient,,,,,16116.81,,,,,,,case rate,,12049.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12049.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17523.34,,,,,,,case rate,,18482.57,,,,,,,case rate,,15560.06,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12049.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11446.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12049.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12049.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12049.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12651.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12049.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12049.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12049.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12651.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12049.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12049.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12049.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16758.3,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16758.3,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12049.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12049.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18482.57,,facility
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,120,RC,,,,inpatient,,,,,16404.34,,,,,,,case rate,,12077.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12063,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12077.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17763.12,,,,,,,case rate,,18735.48,,,,,,,case rate,,15772.97,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12077.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11473.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12077.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12077.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12077.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12681.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12077.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12077.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12077.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12681.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12077.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12077.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12077.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16987.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16987.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12077.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12077.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18735.48,,facility
HEADACHES WITH MCC,102,MS-DRG,120,RC,,,,inpatient,,,,,17455.11,,,,,,,case rate,,12627.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12627.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19815.99,,,,,,,case rate,,20900.73,,,,,,,case rate,,17595.85,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12627.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11996.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12627.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12627.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12627.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13259.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12627.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12627.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12627.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13259.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12627.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12627.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12627.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18950.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18950.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12627.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12627.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20900.73,,facility
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,120,RC,,,,inpatient,,,,,81723.65,,,,,,,case rate,,59765.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,59765.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,90411.9,,,,,,,case rate,,95361.07,,,,,,,case rate,,80282.33,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,59765.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,56777.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59765.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59765.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59765.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,62754.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,59765.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59765.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,59765.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62754.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,59765.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59765.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59765.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,86464.67,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,86464.67,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,59765.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59765.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,95361.07,,facility
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,120,RC,,,,inpatient,,,,,69137,,,,,,,case rate,,55102.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,55102.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,76343.96,,,,,,,case rate,,80523.05,,,,,,,case rate,,67790.53,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,55102.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52347.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55102.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55102.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55102.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,57857.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,55102.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55102.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,55102.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,57857.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,55102.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55102.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55102.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73010.91,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73010.91,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55102.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,55102.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,80523.05,,facility
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,120,RC,,,,inpatient,,,,,33857.95,,,,,,,case rate,,24092.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24092.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37161.96,,,,,,,case rate,,39196.22,,,,,,,case rate,,32998.41,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,24092.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22887.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24092.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24092.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24092.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25297.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24092.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24092.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24092.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25297.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24092.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24092.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24092.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35539.54,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35539.54,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24092.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24092.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,39196.22,,facility
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,120,RC,,,,inpatient,,,,,29492.29,,,,,,,case rate,,21810.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21810.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31466.47,,,,,,,case rate,,33188.95,,,,,,,case rate,,27941.03,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21810.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20719.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21810.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21810.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21810.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22900.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21810.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21810.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21810.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22900.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21810.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21810.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21810.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30092.7,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30092.7,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21810.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21810.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,33188.95,,facility
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,120,RC,,,,inpatient,,,,,28458.08,,,,,,,case rate,,19929.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19929.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30024.53,,,,,,,case rate,,31668.08,,,,,,,case rate,,26660.64,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19929.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18933.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19929.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19929.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19929.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20926.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19929.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19929.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19929.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20926.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19929.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19929.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19929.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28713.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28713.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19929.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19929.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,31668.08,,facility
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,120,RC,,,,inpatient,,,,,16101.76,,,,,,,case rate,,12397.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12397.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19517.09,,,,,,,case rate,,20585.46,,,,,,,case rate,,17330.44,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12397.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11778.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12397.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12397.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12397.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13017.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12397.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12397.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12397.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13017.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12397.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12397.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12397.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18665.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18665.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12397.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12397.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20585.46,,facility
HEADACHES WITHOUT MCC,103,MS-DRG,120,RC,,,,inpatient,,,,,12798.91,,,,,,,case rate,,9543.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9543.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13834.74,,,,,,,case rate,,14592.05,,,,,,,case rate,,12284.72,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9543.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9066.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9543.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9543.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9543.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10020.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9543.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9543.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9543.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10020.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9543.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9543.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9543.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13230.73,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13230.73,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9543.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9543.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14592.05,,facility
FOOT PROCEDURES WITH CC,504,MS-DRG,120,RC,,,,inpatient,,,,,26419.77,,,,,,,case rate,,20737.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20737.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28364.16,,,,,,,case rate,,29916.83,,,,,,,case rate,,25186.3,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20737.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19700.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20737.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20737.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20737.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21774.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20737.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20737.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20737.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21774.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20737.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20737.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20737.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27125.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27125.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20737.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20737.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29916.83,,facility
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,120,RC,,,,inpatient,,,,,40085.79,,,,,,,case rate,,29206.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29206.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,43506.17,,,,,,,case rate,,45887.71,,,,,,,case rate,,38631.83,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,29206.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27746.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29206.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29206.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29206.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30667.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29206.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29206.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29206.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30667.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29206.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29206.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29206.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41606.76,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41606.76,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29206.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29206.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,45887.71,,facility
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,120,RC,,,,inpatient,,,,,32302.87,,,,,,,case rate,,24437.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24437.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34365.13,,,,,,,case rate,,36246.28,,,,,,,case rate,,30514.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,24437.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23215.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24437.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24437.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24437.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25659.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24437.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24437.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24437.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25659.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24437.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24437.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24437.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32864.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32864.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24437.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24437.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36246.28,,facility
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,120,RC,,,,inpatient,,,,,75378.39,,,,,,,case rate,,52546,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,52546,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,78117.64,,,,,,,case rate,,82393.83,,,,,,,case rate,,69365.5,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,52546,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,49918.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52546,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52546,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52546,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,55173.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,52546,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52546,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,52546,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,55173.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,52546,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52546,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52546,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,74707.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,74707.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52546,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52546,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,82393.83,,facility
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,120,RC,,,,inpatient,,,,,25304.27,,,,,,,case rate,,18409.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18409.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27170.21,,,,,,,case rate,,28657.52,,,,,,,case rate,,24126.12,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18409.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17488.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18409.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18409.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18409.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19329.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18409.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18409.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18409.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19329.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18409.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18409.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18409.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25984.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25984.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18409.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18409.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28657.52,,facility
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,120,RC,,,,inpatient,,,,,48239.04,,,,,,,case rate,,39563.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39563.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52563.45,,,,,,,case rate,,55440.79,,,,,,,case rate,,46674.35,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,39563.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37585.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39563.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39563.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39563.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41542.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39563.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39563.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39563.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41542.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39563.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39563.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39563.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50268.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50268.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39563.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39563.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,55440.79,,facility
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,120,RC,,,,inpatient,,,,,18642.87,,,,,,,case rate,,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20326.75,,,,,,,case rate,,21439.44,,,,,,,case rate,,18049.38,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11954.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13212.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13212.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19439.32,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19439.32,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,21439.44,,facility
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,120,RC,,,,inpatient,,,,,20211.5,,,,,,,case rate,,13574.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13574.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23442.19,,,,,,,case rate,,24725.42,,,,,,,case rate,,20815.77,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13574.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12896.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13574.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13574.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13574.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14253.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13574.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13574.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13574.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14253.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13574.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13574.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13574.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22418.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22418.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13574.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13574.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24725.42,,facility
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,120,RC,,,,inpatient,,,,,16977.9,,,,,,,case rate,,12875.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12875.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19641.91,,,,,,,case rate,,20717.11,,,,,,,case rate,,17441.27,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12875.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12232.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12875.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12875.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12875.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13519.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12875.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12875.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12875.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13519.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12875.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12875.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12875.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18784.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18784.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12875.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12875.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20717.11,,facility
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,120,RC,,,,inpatient,,,,,92381.88,,,,,,,case rate,,60334.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,60334.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,111980.23,,,,,,,case rate,,118110.06,,,,,,,case rate,,99434.19,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,60334.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,57318.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60334.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60334.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60334.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,63351.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,60334.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60334.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,60334.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,63351.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,60334.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60334.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60334.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107091.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,107091.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,60334.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,60334.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,118110.06,,facility
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,120,RC,,,,inpatient,,,,,12291.59,,,,,,,case rate,,9481.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9481.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13539.12,,,,,,,case rate,,14280.26,,,,,,,case rate,,12022.23,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9481.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9007.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9481.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9481.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9481.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9955.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9481.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9481.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9481.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9955.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9481.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9481.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9481.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12948.03,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12948.03,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9481.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9481.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14280.26,,facility
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,120,RC,,,,inpatient,,,,,10739.52,,,,,,,case rate,,8279.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8279.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11657.05,,,,,,,case rate,,12295.16,,,,,,,case rate,,10351.01,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8279.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7865.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8279.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8279.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8279.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8693.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8279.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8279.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8279.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8693.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8279.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8279.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8279.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11148.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11148.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8279.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8279.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12295.16,,facility
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,120,RC,,,,inpatient,,,,,46044.16,,,,,,,case rate,,34175.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34175.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,48498.76,,,,,,,case rate,,51153.6,,,,,,,case rate,,43065.06,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,34175.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32466.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34175.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34175.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34175.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,35884.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34175.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34175.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34175.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35884.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34175.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34175.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34175.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46381.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46381.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34175.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34175.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,51153.6,,facility
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,120,RC,,,,inpatient,,,,,40897.2,,,,,,,case rate,,30107.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30107.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44905.41,,,,,,,case rate,,47363.54,,,,,,,case rate,,39874.3,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,30107.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28601.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30107.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30107.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30107.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31612.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30107.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30107.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30107.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31612.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30107.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30107.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30107.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42944.92,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42944.92,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30107.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30107.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,47363.54,,facility
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,120,RC,,,,inpatient,,,,,82352.91,,,,,,,case rate,,62980.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62980.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,62980.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,59831.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62980.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62980.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62980.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,66129.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,62980.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62980.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62980.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,66129.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,62980.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62980.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62980.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62980.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62980.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,82352.91,,facility
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,120,RC,,,,inpatient,,,,,39491.16,,,,,,,case rate,,30261.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30261.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,43842.84,,,,,,,case rate,,46242.81,,,,,,,case rate,,38930.78,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,30261.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28748.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30261.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30261.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30261.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31774.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30261.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30261.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30261.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31774.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30261.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30261.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30261.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41928.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41928.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30261.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30261.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,46242.81,,facility
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,120,RC,,,,inpatient,,,,,13149.67,,,,,,,case rate,,10860.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10860.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 10230.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,11529,,,,,,,case rate,,12984,,,,,,,case rate,,12633.25,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10860.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10317.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10860.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10860.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17858,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10860.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17858,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11403.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10860.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10860.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10860.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2122,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1804,,,,,,,per diem,,11403.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10860.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10860.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10860.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 14228.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 16055.00,16087,16087,16415.57,1 through 10,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10860.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10860.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17858,,facility
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,120,RC,,,,inpatient,,,,,100544.16,,,,,,,case rate,,78213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,78213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,113642.23,,,,,,,case rate,,119863.04,,,,,,,case rate,,100909.99,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,78213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,74302.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,82123.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,78213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,78213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,82123.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,78213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,78213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108680.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,108680.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,78213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,119863.04,,facility
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,120,RC,,,,inpatient,,,,,70029.7,,,,,,,case rate,,50532.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,50532.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,78541.36,,,,,,,case rate,,82840.73,,,,,,,case rate,,69741.74,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,50532.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48005.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50532.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50532.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50532.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,53059.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50532.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50532.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,50532.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,53059.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50532.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50532.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50532.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,75112.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,75112.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50532.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50532.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,82840.73,,facility
CONCUSSION WITH MCC,088,MS-DRG,120,RC,,,,inpatient,,,,,21236.68,,,,,,,case rate,,15130.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15130.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25189.6,,,,,,,case rate,,26568.48,,,,,,,case rate,,22367.41,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15130.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14373.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15130.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15130.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15130.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15886.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15130.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15130.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15130.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15886.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15130.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15130.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15130.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24089.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24089.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15130.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15130.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26568.48,,facility
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,120,RC,,,,inpatient,,,,,81910.32,,,,,,,case rate,,61219.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,61219.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,86412.9,,,,,,,case rate,,91143.17,,,,,,,case rate,,76731.37,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,61219.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,58158.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61219.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61219.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61219.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,64280.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,61219.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61219.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,61219.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,64280.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,61219.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,61219.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61219.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,61219.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61219.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,91143.17,,facility
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,120,RC,,,,inpatient,,,,,26311.38,,,,,,,case rate,,19618.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19618.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28546.46,,,,,,,case rate,,30109.1,,,,,,,case rate,,25348.17,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19618.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18637.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19618.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19618.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19618.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20599.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19618.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19618.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19618.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20599.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19618.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19618.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19618.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27300.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27300.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19618.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19618.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30109.1,,facility
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,120,RC,,,,inpatient,,,,,30568,,,,,,,case rate,,16827.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24849,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16827.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24918.62,,,,,,,case rate,,26282.67,,,,,,,case rate,,22126.79,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16827.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15985.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16827.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16827.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16827.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17668.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16827.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16827.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16827.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17668.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16827.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16827.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16827.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23830.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23830.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16827.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16827.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30568,,facility
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,120,RC,,,,inpatient,,,,,22016.47,,,,,,,case rate,,16790.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16790.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25968.05,,,,,,,case rate,,27389.55,,,,,,,case rate,,23058.64,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16790.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15950.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16790.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16790.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16790.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17629.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16790.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16790.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16790.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17629.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16790.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16790.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16790.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24834.33,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24834.33,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16790.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16790.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27389.55,,facility
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,120,RC,,,,inpatient,,,,,49067.01,,,,,,,case rate,,35576.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35576.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,54888.95,,,,,,,case rate,,57893.59,,,,,,,case rate,,48739.3,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,35576.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33798.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35576.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35576.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35576.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37355.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35576.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35576.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35576.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37355.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35576.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35576.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35576.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52492.59,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52492.59,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35576.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35576.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,57893.59,,facility
REHABILITATION WITH CC/MCC,945,MS-DRG,120,RC,,,,inpatient,,,,,22979.93,,,,,,,case rate,,17262.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17262.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24790.52,,,,,,,case rate,,26147.56,,,,,,,case rate,,22013.04,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17262.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16399.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17262.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17262.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17262.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18126.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17262.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17262.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17262.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18126.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17262.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17262.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17262.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23708.21,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23708.21,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17262.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17262.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26147.56,,facility
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,120,RC,,,,inpatient,,,,,83920.03,,,,,,,case rate,,56795.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,56795.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,88907.55,,,,,,,case rate,,93774.38,,,,,,,case rate,,78946.53,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,56795.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,53955.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,56795.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,56795.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,56795.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,59635.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,56795.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,56795.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,56795.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,59635.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,56795.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,56795.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,56795.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,85026,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,85026,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,56795.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,56795.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,93774.38,,facility
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,120,RC,,,,inpatient,,,,,15937.67,,,,,,,case rate,,11566.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11566.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16851.64,,,,,,,case rate,,17774.1,,,,,,,case rate,,14963.62,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11566.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10988.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11566.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11566.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11566.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12145.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11566.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11566.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11566.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12145.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11566.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11566.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11566.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16115.93,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16115.93,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11566.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11566.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17774.1,,facility
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,120,RC,,,,inpatient,,,,,25209.43,,,,,,,case rate,,19305.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19305.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27526.59,,,,,,,case rate,,29033.4,,,,,,,case rate,,24442.57,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19305.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18340.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19305.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19305.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19305.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20270.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19305.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19305.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19305.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20270.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19305.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19305.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19305.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26324.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26324.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19305.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19305.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29033.4,,facility
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,120,RC,,,,inpatient,,,,,21033.45,,,,,,,case rate,,15066.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15066.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22708.08,,,,,,,case rate,,23951.13,,,,,,,case rate,,20163.91,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15066.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14312.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15066.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15066.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15066.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15819.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15066.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15066.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15066.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15819.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15066.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15066.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15066.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21716.69,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21716.69,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15066.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15066.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23951.13,,facility
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,120,RC,,,,inpatient,,,,,24729.21,,,,,,,case rate,,19168.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19168.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24994.16,,,,,,,case rate,,26362.35,,,,,,,case rate,,22193.87,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19168.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18209.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19168.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19168.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19168.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20126.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19168.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19168.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19168.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20126.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19168.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19168.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19168.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23902.96,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23902.96,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19168.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19168.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26362.35,,facility
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,120,RC,,,,inpatient,,,,,38968.78,,,,,,,case rate,,28306.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28306.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41339.98,,,,,,,case rate,,43602.94,,,,,,,case rate,,36708.33,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,28306.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26890.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28306.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28306.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28306.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29721.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28306.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28306.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28306.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29721.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28306.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28306.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28306.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39535.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39535.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28306.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28306.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,43602.94,,facility
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,120,RC,,,,inpatient,,,,,43111.65,,,,,,,case rate,,29307.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29307.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46744.78,,,,,,,case rate,,49303.61,,,,,,,case rate,,41507.59,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,29307.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27842.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29307.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29307.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29307.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30772.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29307.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29307.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29307.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30772.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29307.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29307.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29307.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44703.99,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44703.99,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29307.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29307.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,49303.61,,facility
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,120,RC,,,,inpatient,,,,,89560.76,,,,,,,case rate,,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,93556.9,,,,,,,case rate,,98678.24,,,,,,,case rate,,83074.98,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,68151.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,75325.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,75325.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,89472.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,89472.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,98678.24,,facility
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,120,RC,,,,inpatient,,,,,30365.42,,,,,,,case rate,,22102.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22102.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32913.33,,,,,,,case rate,,34715.02,,,,,,,case rate,,29225.79,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22102.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20997.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22102.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22102.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22102.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23207.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22102.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22102.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22102.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23207.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22102.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22102.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22102.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31476.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31476.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22102.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22102.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,34715.02,,facility
NON-EXTENSIVE BURNS,935,MS-DRG,120,RC,,,,inpatient,,,,,33064.61,,,,,,,case rate,,22805.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22805.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33520.99,,,,,,,case rate,,35355.93,,,,,,,case rate,,29765.36,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22805.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21664.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22805.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22805.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22805.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23945.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22805.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22805.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22805.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23945.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22805.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22805.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22805.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32057.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32057.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22805.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22805.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,35355.93,,facility
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,120,RC,,,,inpatient,,,,,10578.45,,,,,,,case rate,,8063.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8063.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11737.52,,,,,,,case rate,,12380.03,,,,,,,case rate,,10422.47,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8063.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7659.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8063.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8063.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8063.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8466.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8063.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8063.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8063.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8466.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8063.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8063.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8063.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11225.08,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11225.08,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8063.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8063.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12380.03,,facility
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,120,RC,,,,inpatient,,,,,33606.55,,,,,,,case rate,,24740.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24740.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36657.78,,,,,,,case rate,,38664.44,,,,,,,case rate,,32550.71,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,24740.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23503.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24740.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24740.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24740.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25977.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24740.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24740.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24740.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25977.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24740.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24740.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24740.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35057.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35057.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24740.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24740.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,38664.44,,facility
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,120,RC,,,,inpatient,,,,,30058.32,,,,,,,case rate,,19954.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19954.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33601.46,,,,,,,case rate,,35440.81,,,,,,,case rate,,29836.82,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19954.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18957.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19954.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19954.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19954.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20952.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19954.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19954.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19954.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20952.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19954.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19954.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19954.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32134.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32134.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19954.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19954.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,35440.81,,facility
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,120,RC,,,,inpatient,,,,,24482.32,,,,,,,case rate,,17424.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17424.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25261.86,,,,,,,case rate,,26644.7,,,,,,,case rate,,22431.57,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17424.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16553.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17424.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17424.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17424.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18295.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17424.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17424.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17424.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18295.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17424.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17424.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17424.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24158.97,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24158.97,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17424.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17424.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26644.7,,facility
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,120,RC,,,,inpatient,,,,,26866.87,,,,,,,case rate,,19424.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19424.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28505.4,,,,,,,case rate,,30065.8,,,,,,,case rate,,25311.71,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19424.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18453.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19424.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19424.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19424.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20396.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19424.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19424.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19424.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20396.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19424.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19424.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19424.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27260.9,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27260.9,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19424.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19424.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30065.8,,facility
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,120,RC,,,,inpatient,,,,,25948.58,,,,,,,case rate,,19933.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19933.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28114.53,,,,,,,case rate,,29653.53,,,,,,,case rate,,24964.64,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19933.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18936.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19933.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19933.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19933.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20929.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19933.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19933.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19933.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20929.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19933.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19933.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19933.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26887.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26887.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19933.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19933.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29653.53,,facility
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,120,RC,,,,inpatient,,,,,49992.83,,,,,,,case rate,,36157.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36157.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55437.48,,,,,,,case rate,,58472.14,,,,,,,case rate,,49226.37,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,36157.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,34349.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36157.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36157.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36157.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37965.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,36157.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36157.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36157.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37965.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,36157.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36157.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36157.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53017.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,53017.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36157.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36157.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,58472.14,,facility
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,120,RC,,,,inpatient,,,,,26026.86,,,,,,,case rate,,20092.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20092.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30789.84,,,,,,,case rate,,32475.29,,,,,,,case rate,,27340.21,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20092.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19087.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20092.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20092.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20092.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21097.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20092.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20092.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20092.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21097.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20092.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20092.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20092.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29445.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29445.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20092.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20092.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32475.29,,facility
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,120,RC,,,,inpatient,,,,,19836.66,,,,,,,case rate,,14724.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14724.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21786.75,,,,,,,case rate,,22979.37,,,,,,,case rate,,19345.81,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14724.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13988.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14724.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14724.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14724.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15461,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14724.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14724.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14724.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15461,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14724.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14724.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14724.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20835.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20835.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14724.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14724.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22979.37,,facility
APPENDIX PROCEDURES WITH CC,398,MS-DRG,120,RC,,,,inpatient,,,,,22779.71,,,,,,,case rate,,16883.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16883.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24852.93,,,,,,,case rate,,26213.38,,,,,,,case rate,,22068.45,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16883.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16039.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16883.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16883.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16883.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17727.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16883.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16883.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16883.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17727.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16883.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16883.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16883.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23767.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23767.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16883.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16883.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26213.38,,facility
RENAL FAILURE WITH MCC,682,MS-DRG,120,RC,,,,inpatient,,,,,22609.6,,,,,,,case rate,,16530.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16530.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24647.64,,,,,,,case rate,,25996.86,,,,,,,case rate,,21886.17,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16530.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15703.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16530.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16530.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16530.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17356.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16530.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16530.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16530.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17356.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16530.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16530.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16530.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23571.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23571.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16530.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16530.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25996.86,,facility
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,120,RC,,,,inpatient,,,,,44388.22,,,,,,,case rate,,34235.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34235.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49291.99,,,,,,,case rate,,51990.25,,,,,,,case rate,,43769.42,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,34235.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32523.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34235.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34235.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34235.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,35946.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34235.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34235.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34235.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35946.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34235.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34235.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34235.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,47139.99,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47139.99,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34235.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34235.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,51990.25,,facility
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,120,RC,,,,inpatient,,,,,22471.11,,,,,,,case rate,,17133.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17133.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24542.53,,,,,,,case rate,,25886,,,,,,,case rate,,21792.84,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17133.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16277.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17133.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17133.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17133.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17990.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17133.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17133.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17133.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17990.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17133.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17133.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17133.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23471.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23471.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17133.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17133.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25886,,facility
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,120,RC,,,,inpatient,,,,,43161.32,,,,,,,case rate,,33210,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33210,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47974.87,,,,,,,case rate,,50601.03,,,,,,,case rate,,42599.86,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,33210,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31549.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33210,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33210,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33210,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,34870.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33210,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33210,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33210,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34870.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33210,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33210,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33210,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45880.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45880.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33210,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33210,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,50601.03,,facility
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,120,RC,,,,inpatient,,,,,20917.53,,,,,,,case rate,,18793.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18793.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25355.47,,,,,,,case rate,,26743.44,,,,,,,case rate,,22514.69,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18793.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17853.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18793.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18793.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18793.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19732.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18793.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18793.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18793.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19732.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18793.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18793.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18793.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24248.49,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24248.49,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18793.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18793.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26743.44,,facility
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,120,RC,,,,inpatient,,,,,12949.45,,,,,,,case rate,,9596.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9596.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14044.95,,,,,,,case rate,,14813.77,,,,,,,case rate,,12471.38,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9596.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9116.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9596.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9596.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,28687.08,28687.08,28687.08,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,9596.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10076.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9596.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9596.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9596.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10076.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9596.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9596.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9596.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13431.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13431.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9596.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9596.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14813.77,,facility
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,120,RC,,,,inpatient,,,,,15454.44,,,,,,,case rate,,11701.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11701.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17217.87,,,,,,,case rate,,18160.38,,,,,,,case rate,,15288.82,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11701.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11116.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11701.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11701.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11701.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12286.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11701.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11701.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11701.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12286.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11701.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11701.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11701.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16466.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16466.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11701.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11701.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18160.38,,facility
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,120,RC,,,,inpatient,,,,,13090.96,,,,,,,case rate,,9743.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9743.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14381.62,,,,,,,case rate,,15168.88,,,,,,,case rate,,12770.33,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9743.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9256.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9743.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9743.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9743.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10231.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9743.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9743.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9743.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10231.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9743.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9743.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9743.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13753.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13753.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9743.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9743.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15168.88,,facility
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,120,RC,,,,inpatient,,,,,27520.22,,,,,,,case rate,,20312.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20312.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30287.3,,,,,,,case rate,,31945.23,,,,,,,case rate,,26893.97,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20312.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19296.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20312.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20312.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20312.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21328.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20312.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20312.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20312.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21328.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20312.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20312.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20312.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28965.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28965.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20312.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20312.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,31945.23,,facility
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,120,RC,,,,inpatient,,,,,26175.9,,,,,,,case rate,,18522.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18522.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29388.96,,,,,,,case rate,,30997.72,,,,,,,case rate,,26096.28,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18522.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17596.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18522.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18522.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18522.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19448.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18522.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18522.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18522.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19448.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18522.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18522.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18522.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28105.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28105.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18522.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18522.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30997.72,,facility
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,120,RC,,,,inpatient,,,,,19336.86,,,,,,,case rate,,14225.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14225.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20950.82,,,,,,,case rate,,22097.68,,,,,,,case rate,,18603.53,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14225.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13513.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14225.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14225.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14225.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14936.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14225.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14225.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14225.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14936.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14225.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14225.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14225.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20036.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20036.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14225.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14225.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22097.68,,facility
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,120,RC,,,,inpatient,,,,,22127.87,,,,,,,case rate,,16484.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16484.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23870.83,,,,,,,case rate,,25177.53,,,,,,,case rate,,21196.39,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16484.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15660.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16484.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16484.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16484.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17308.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16484.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16484.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16484.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17308.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16484.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16484.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16484.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22828.67,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22828.67,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16484.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16484.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25177.53,,facility
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,120,RC,,,,inpatient,,,,,23735.64,,,,,,,case rate,,18978.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18978.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24268.27,,,,,,,case rate,,25596.72,,,,,,,case rate,,21549.3,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18978.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18029.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18978.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18978.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18978.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19927.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18978.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18978.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18978.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19927.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18978.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18978.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18978.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23208.76,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23208.76,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18978.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18978.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25596.72,,facility
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,120,RC,,,,inpatient,,,,,14737.87,,,,,,,case rate,,10555.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10555.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16836.86,,,,,,,case rate,,17758.51,,,,,,,case rate,,14950.49,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10555.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10027.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10555.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10555.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10555.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11083.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10555.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10555.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10555.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11083.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10555.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10555.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10555.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16101.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16101.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10555.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10555.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17758.51,,facility
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,120,RC,,,,inpatient,,,,,30079.4,,,,,,,case rate,,22134.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22134.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33473.36,,,,,,,case rate,,35305.7,,,,,,,case rate,,29723.07,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22134.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21027.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22134.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22134.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22134.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23240.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22134.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22134.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22134.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23240.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22134.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22134.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22134.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32011.97,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32011.97,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22134.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22134.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,35305.7,,facility
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,120,RC,,,,inpatient,,,,,11261.9,,,,,,,case rate,,8600.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8600.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12325.46,,,,,,,case rate,,13000.16,,,,,,,case rate,,10944.54,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8600.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8170.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8600.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8600.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8600.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9030.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8600.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8600.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8600.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9030.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8600.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8600.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8600.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11787.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11787.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8600.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8600.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13000.16,,facility
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,120,RC,,,,inpatient,,,,,29883.7,,,,,,,case rate,,21386.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21386.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27656.33,,,,,,,case rate,,29170.25,,,,,,,case rate,,24557.77,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21386.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20317.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21386.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21386.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21386.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22455.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21386.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21386.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21386.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22455.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21386.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21386.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21386.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26448.9,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26448.9,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21386.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21386.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29883.7,,facility
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,120,RC,,,,inpatient,,,,,13426.66,,,,,,,case rate,,12316.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12316.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16275.19,,,,,,,case rate,,17166.1,,,,,,,case rate,,14451.75,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12316.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11700.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12316.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12316.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12316.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12932.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12316.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12316.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12316.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12932.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12316.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12316.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12316.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15564.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15564.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12316.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12316.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17166.1,,facility
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,120,RC,,,,inpatient,,,,,24459.74,,,,,,,case rate,,17628.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17628.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25733.2,,,,,,,case rate,,27141.84,,,,,,,case rate,,22850.1,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17628.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16746.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17628.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17628.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17628.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18509.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17628.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17628.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17628.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18509.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17628.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17628.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17628.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24609.73,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24609.73,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17628.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17628.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27141.84,,facility
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,120,RC,,,,inpatient,,,,,43901.98,,,,,,,case rate,,32125.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32125.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46280.01,,,,,,,case rate,,48813.4,,,,,,,case rate,,41094.89,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,32125.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30518.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32125.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32125.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32125.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33731.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32125.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32125.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32125.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33731.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32125.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32125.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32125.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44259.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44259.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32125.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32125.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,48813.4,,facility
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,120,RC,,,,inpatient,,,,,25204.91,,,,,,,case rate,,18789.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18789.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27786.07,,,,,,,case rate,,29307.09,,,,,,,case rate,,24672.98,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18789.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17850.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18789.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18789.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18789.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19729.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18789.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18789.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18789.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19729.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18789.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18789.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18789.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26572.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26572.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18789.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18789.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29307.09,,facility
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,120,RC,,,,inpatient,,,,,18627.82,,,,,,,case rate,,13868.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13868.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20233.14,,,,,,,case rate,,21340.7,,,,,,,case rate,,17966.26,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13868.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13175.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13868.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13868.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13868.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14562.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13868.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13868.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13868.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14562.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13868.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13868.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13868.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19349.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19349.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13868.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13868.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,21340.7,,facility
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,120,RC,,,,inpatient,,,,,85884.58,,,,,,,case rate,,62581.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62581.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,93098.7,,,,,,,case rate,,98194.95,,,,,,,case rate,,82668.11,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,62581.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,59452.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62581.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62581.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62581.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,65710.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,62581.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62581.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62581.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,65710.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,62581.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62581.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62581.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,89034.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,89034.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,62581.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62581.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,98194.95,,facility
CELLULITIS WITH MCC,602,MS-DRG,120,RC,,,,inpatient,,,,,22117.34,,,,,,,case rate,,15883.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15883.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24429.21,,,,,,,case rate,,25766.48,,,,,,,case rate,,21692.21,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15883.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15089.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15883.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15883.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15883.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16677.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15883.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15883.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15883.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16677.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15883.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15883.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15883.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23362.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23362.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15883.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15883.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25766.48,,facility
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,120,RC,,,,inpatient,,,,,119337.57,,,,,,,case rate,,77800.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,77800.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,131277.25,,,,,,,case rate,,138463.41,,,,,,,case rate,,116569.21,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,77800.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,73910.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,77800.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,77800.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,77800.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,81690.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,77800.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,77800.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,77800.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,81690.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,77800.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,77800.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,77800.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,77800.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,77800.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,138463.41,,facility
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,120,RC,,,,inpatient,,,,,8422.71,,,,,,,case rate,,6615.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6615.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9081.92,,,,,,,case rate,,9579.07,,,,,,,case rate,,8064.4,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,6615.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6284.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6615.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6615.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6615.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6945.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6615.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6615.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6615.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6945.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6615.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6615.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6615.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8685.42,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8685.42,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6615.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6615.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,9579.07,,facility
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,120,RC,,,,inpatient,,,,,73121.79,,,,,,,case rate,,52810.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,52810.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,80784.74,,,,,,,case rate,,85206.92,,,,,,,case rate,,71733.78,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,52810.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,50169.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52810.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52810.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52810.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,55450.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,52810.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52810.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,52810.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,55450.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,52810.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52810.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52810.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,77257.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,77257.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52810.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52810.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,85206.92,,facility
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,120,RC,,,,inpatient,,,,,25140.18,,,,,,,case rate,,17732.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17732.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27130.8,,,,,,,case rate,,28615.94,,,,,,,case rate,,24091.12,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17732.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16845.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17732.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17732.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17732.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18618.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17732.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17732.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17732.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18618.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17732.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17732.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17732.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25946.31,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25946.31,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17732.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17732.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28615.94,,facility
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,120,RC,,,,inpatient,,,,,28501.74,,,,,,,case rate,,22098.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22098.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30556.63,,,,,,,case rate,,32229.31,,,,,,,case rate,,27133.13,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22098.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20993.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22098.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22098.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22098.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23203.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22098.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22098.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22098.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23203.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22098.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22098.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22098.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29222.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29222.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22098.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22098.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32229.31,,facility
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,120,RC,,,,inpatient,,,,,83207.97,,,,,,,case rate,,59976.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,59976.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,91952.38,,,,,,,case rate,,96985.88,,,,,,,case rate,,81650.22,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,59976.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,56977.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59976.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59976.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59976.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,62974.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,59976.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59976.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,59976.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62974.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,59976.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59976.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59976.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,87937.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,87937.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,59976.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59976.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,96985.88,,facility
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,120,RC,,,,inpatient,,,,,14552.7,,,,,,,case rate,,11005.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11005.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15725.02,,,,,,,case rate,,16585.81,,,,,,,case rate,,13963.22,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11005.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10455.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11005.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11005.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11005.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11555.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11005.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11005.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11005.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11555.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11005.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11005.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11005.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15038.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15038.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11005.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11005.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16585.81,,facility
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,120,RC,,,,inpatient,,,,,15353.57,,,,,,,case rate,,11480.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11480.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16764.6,,,,,,,case rate,,17682.3,,,,,,,case rate,,14886.33,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11480.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10906.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11480.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11480.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11480.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12054.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11480.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11480.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11480.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12054.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11480.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11480.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11480.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16032.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16032.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11480.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11480.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17682.3,,facility
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,120,RC,,,,inpatient,,,,,34478.18,,,,,,,case rate,,24407.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24407.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35968.01,,,,,,,case rate,,37936.91,,,,,,,case rate,,31938.23,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,24407.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23187.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24407.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24407.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24407.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25628.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24407.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24407.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24407.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25628.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24407.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24407.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24407.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34397.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34397.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24407.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24407.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,37936.91,,facility
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,120,RC,,,,inpatient,,,,,27595.49,,,,,,,case rate,,21534.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21534.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29696.07,,,,,,,case rate,,31321.64,,,,,,,case rate,,26368.98,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21534.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20458.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21534.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21534.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21534.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22611.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21534.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21534.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21534.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22611.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21534.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21534.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21534.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28399.59,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28399.59,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21534.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21534.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,31321.64,,facility
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,120,RC,,,,inpatient,,,,,27788.18,,,,,,,case rate,,19006.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19006.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28377.3,,,,,,,case rate,,29930.68,,,,,,,case rate,,25197.97,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19006.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18056.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19006.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19006.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19006.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19956.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19006.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19006.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19006.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19956.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19006.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19006.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19006.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27138.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27138.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19006.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19006.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29930.68,,facility
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,120,RC,,,,inpatient,,,,,16714.46,,,,,,,case rate,,12086.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12086.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18083.37,,,,,,,case rate,,19073.25,,,,,,,case rate,,16057.34,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12086.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11482.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12086.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12086.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12086.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12691.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12086.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12086.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12086.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12691.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12086.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12086.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12086.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17293.88,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17293.88,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12086.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12086.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,19073.25,,facility
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,120,RC,,,,inpatient,,,,,46962.46,,,,,,,case rate,,33658.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33658.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49214.8,,,,,,,case rate,,51908.84,,,,,,,case rate,,43700.88,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,33658.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31975.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33658.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33658.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33658.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,35341.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33658.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33658.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33658.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35341.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33658.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33658.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33658.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,47066.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47066.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33658.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33658.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,51908.84,,facility
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,120,RC,,,,inpatient,,,,,25113.08,,,,,,,case rate,,19055.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19055.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26854.89,,,,,,,case rate,,28324.93,,,,,,,case rate,,23846.12,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19055.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18102.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19055.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19055.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19055.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20008.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19055.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19055.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19055.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20008.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19055.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19055.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19055.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25682.45,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25682.45,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19055.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19055.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28324.93,,facility
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,120,RC,,,,inpatient,,,,,24334.79,,,,,,,case rate,,17415.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17415.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27859.98,,,,,,,case rate,,29385.04,,,,,,,case rate,,24738.6,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17415.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16544.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17415.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17415.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17415.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18286.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17415.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17415.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17415.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18286.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17415.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17415.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17415.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26643.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26643.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17415.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17415.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29385.04,,facility
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,120,RC,,,,inpatient,,,,,21768.08,,,,,,,case rate,,16773.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16773.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23824.85,,,,,,,case rate,,25129.03,,,,,,,case rate,,21155.56,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16773.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15934.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16773.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16773.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16773.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17611.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16773.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16773.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16773.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17611.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16773.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16773.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16773.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22784.69,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22784.69,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16773.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16773.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25129.03,,facility
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,120,RC,,,,inpatient,,,,,51276.93,,,,,,,case rate,,35731.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35731.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,54445.53,,,,,,,case rate,,57425.89,,,,,,,case rate,,48345.56,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,35731.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33945.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35731.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35731.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35731.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37518.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35731.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35731.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35731.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37518.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35731.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35731.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35731.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52068.53,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52068.53,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35731.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35731.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,57425.89,,facility
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,120,RC,,,,inpatient,,,,,9593.91,,,,,,,case rate,,7786.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7786.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 3.00 + Fixed Amount 8669.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,7842,,,,,,,case rate,,8095,,,,,,,case rate,,9541.66,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7786.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7397.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7786.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7786.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7786.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8176.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7786.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7786.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7786.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2122,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1804,,,,,,,per diem,,8176.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7786.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7786.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7786.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 2.00 + Fixed Amount 11638.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Outlier Per Diem Second Dollar + Days Threshold 2.00 + Fixed Amount 13781.00,21769.4,13836,21769.4,24,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7786.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7786.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16374,,facility
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,120,RC,,,,inpatient,,,,,8451.32,,,,,,,case rate,,6970.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6970.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8025.92,,,,,,,case rate,,8465.26,,,,,,,case rate,,7126.71,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,6970.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6622.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6970.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6970.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6970.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7319.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6970.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6970.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6970.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7319.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6970.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6970.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6970.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7675.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7675.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6970.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6970.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,8465.26,,facility
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,120,RC,,,,inpatient,,,,,19129.12,,,,,,,case rate,,14657.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14657.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19914.53,,,,,,,case rate,,21004.66,,,,,,,case rate,,17683.35,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14657.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13924.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14657.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14657.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14657.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15390.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14657.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14657.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14657.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15390.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14657.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14657.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14657.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19045.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19045.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14657.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14657.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,21004.66,,facility
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,120,RC,,,,inpatient,,,,,13876.78,,,,,,,case rate,,10440.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10440.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14994.2,,,,,,,case rate,,15814.99,,,,,,,case rate,,13314.28,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10440.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9918.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10440.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10440.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10440.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10962.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10440.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10440.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10440.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10962.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10440.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10440.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10440.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14339.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14339.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10440.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10440.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15814.99,,facility
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,120,RC,,,,inpatient,,,,,13834.63,,,,,,,case rate,,10822.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10822.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15881.04,,,,,,,case rate,,16750.37,,,,,,,case rate,,14101.76,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10822.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10281.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10822.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10822.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10822.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11363.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10822.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10822.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10822.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11363.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10822.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10822.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10822.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15187.7,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15187.7,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10822.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10822.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16750.37,,facility
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,120,RC,,,,inpatient,,,,,9584.88,,,,,,,case rate,,7312,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7312,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10399.04,,,,,,,case rate,,10968.29,,,,,,,case rate,,9233.96,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7312,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6946.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7312,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7312,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7312,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7677.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7312,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7312,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7312,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7677.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7312,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7312,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7312,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9945.04,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9945.04,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7312,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7312,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,10968.29,,facility
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,120,RC,,,,inpatient,,,,,24018.66,,,,,,,case rate,,18501.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18501.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26652.89,,,,,,,case rate,,28111.87,,,,,,,case rate,,23666.75,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18501.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17576.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18501.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18501.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18501.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19426.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18501.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18501.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18501.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19426.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18501.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18501.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18501.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25489.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25489.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18501.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18501.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28111.87,,facility
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,120,RC,,,,inpatient,,,,,31235.54,,,,,,,case rate,,23178.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23178.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34076.08,,,,,,,case rate,,35941.42,,,,,,,case rate,,30258.27,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23178.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22020,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23178.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23178.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23178.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24337.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23178.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23178.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23178.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24337.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23178.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23178.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23178.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32588.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32588.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23178.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23178.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,35941.42,,facility
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,120,RC,,,,inpatient,,,,,36856.71,,,,,,,case rate,,27123.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27123.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40827.58,,,,,,,case rate,,43062.49,,,,,,,case rate,,36253.34,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,27123.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25767.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27123.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27123.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27123.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28479.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27123.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27123.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27123.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28479.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27123.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27123.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27123.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39045.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39045.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27123.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27123.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,43062.49,,facility
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,120,RC,,,,inpatient,,,,,22031.53,,,,,,,case rate,,15921.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15921.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24974.46,,,,,,,case rate,,26341.57,,,,,,,case rate,,22176.37,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15921.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15125.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15921.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15921.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15921.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16717.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15921.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15921.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15921.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16717.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15921.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15921.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15921.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23884.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23884.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15921.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15921.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26341.57,,facility
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,120,RC,,,,inpatient,,,,,71578.76,,,,,,,case rate,,49561.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49561.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,81369.4,,,,,,,case rate,,85823.58,,,,,,,case rate,,72252.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,49561.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47083.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49561.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49561.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49561.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52039.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49561.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49561.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49561.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,52039.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49561.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49561.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49561.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,77816.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,77816.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49561.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49561.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,85823.58,,facility
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,120,RC,,,,inpatient,,,,,20931.08,,,,,,,case rate,,15606.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15606.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22276.16,,,,,,,case rate,,23495.56,,,,,,,case rate,,19780.38,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15606.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14826.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15606.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15606.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15606.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16387.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15606.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15606.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15606.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16387.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15606.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15606.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15606.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21303.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21303.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15606.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15606.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23495.56,,facility
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,120,RC,,,,inpatient,,,,,49045.93,,,,,,,case rate,,34984.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34984.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,51528.8,,,,,,,case rate,,54349.51,,,,,,,case rate,,45755.62,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,34984.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33234.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34984.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34984.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34984.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36733.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34984.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34984.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34984.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36733.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34984.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34984.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34984.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49279.15,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49279.15,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34984.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34984.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,54349.51,,facility
PNEUMOTHORAX WITH CC,200,MS-DRG,120,RC,,,,inpatient,,,,,16672.3,,,,,,,case rate,,12393.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12393.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17687.57,,,,,,,case rate,,18655.79,,,,,,,case rate,,15705.89,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12393.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11773.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12393.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12393.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12393.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13013.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12393.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12393.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12393.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13013.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12393.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12393.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12393.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16915.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16915.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12393.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12393.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18655.79,,facility
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,120,RC,,,,inpatient,,,,,10108.76,,,,,,,case rate,,8286.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8286.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11645.55,,,,,,,case rate,,12283.03,,,,,,,case rate,,10340.81,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8286.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7871.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8286.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8286.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8286.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8700.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8286.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8286.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8286.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8700.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8286.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8286.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8286.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11137.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11137.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8286.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8286.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12283.03,,facility
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,120,RC,,,,inpatient,,,,,12964.5,,,,,,,case rate,,9681.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9681.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14066.3,,,,,,,case rate,,14836.29,,,,,,,case rate,,12490.34,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9681.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9197.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9681.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9681.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9681.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10165.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9681.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9681.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9681.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10165.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9681.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9681.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9681.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13452.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13452.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9681.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9681.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14836.29,,facility
SYNCOPE AND COLLAPSE,312,MS-DRG,120,RC,,,,inpatient,,,,,13116.55,,,,,,,case rate,,9925.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9925.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14181.26,,,,,,,case rate,,14957.55,,,,,,,case rate,,12592.42,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9925.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9429.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9925.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9925.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9925.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10422.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9925.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9925.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9925.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10422.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9925.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9925.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9925.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13562.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13562.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9925.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9925.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14957.55,,facility
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,120,RC,,,,inpatient,,,,,16303.48,,,,,,,case rate,,11968.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11968.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 10230.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,11529,,,,,,,case rate,,12984,,,,,,,case rate,,14934.45,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11968.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11370.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11968.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11968.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17858,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11968.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17858,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12567.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11968.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11968.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11968.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2122,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1804,,,,,,,per diem,,12567.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11968.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11968.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11968.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 14228.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 16055.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,11968.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11968.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17858,,facility
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,120,RC,,,,inpatient,,,,,58894.26,,,,,,,case rate,,44051.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,44051.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,44051.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41849.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44051.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44051.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44051.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,46254.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,44051.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44051.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,44051.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46254.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,44051.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44051.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44051.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,44051.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44051.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,58894.26,,facility
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,120,RC,,,,inpatient,,,,,38039.95,,,,,,,case rate,,27375.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27375.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40945.82,,,,,,,case rate,,43187.21,,,,,,,case rate,,36358.34,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,27375.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26006.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27375.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27375.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27375.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28743.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27375.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27375.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27375.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28743.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27375.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27375.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27375.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39158.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39158.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27375.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27375.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,43187.21,,facility
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,120,RC,,,,inpatient,,,,,30083.91,,,,,,,case rate,,22811.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22811.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32415.72,,,,,,,case rate,,34190.16,,,,,,,case rate,,28783.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22811.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21671,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22811.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22811.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22811.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23952.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22811.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22811.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22811.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23952.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22811.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22811.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22811.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31000.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31000.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22811.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22811.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,34190.16,,facility
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,120,RC,,,,inpatient,,,,,12044.71,,,,,,,case rate,,9137.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12425,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9137.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13117.05,,,,,,,case rate,,13835.08,,,,,,,case rate,,11647.44,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9137.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8680.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9137.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9137.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9137.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9593.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9137.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9137.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9137.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9593.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9137.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9137.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9137.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12544.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12544.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9137.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9137.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13835.08,,facility
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,120,RC,,,,inpatient,,,,,59928.47,,,,,,,case rate,,39308.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39308.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,59390.49,,,,,,,case rate,,62641.55,,,,,,,case rate,,52736.5,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,39308.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37342.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39308.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39308.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39308.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41273.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39308.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39308.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39308.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41273.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39308.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39308.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39308.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,56797.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,56797.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39308.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39308.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,62641.55,,facility
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,120,RC,,,,inpatient,,,,,10604.04,,,,,,,case rate,,7351.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7351.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11965.8,,,,,,,case rate,,12620.81,,,,,,,case rate,,10625.17,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7351.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6983.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7351.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7351.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7351.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7718.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7351.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7351.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7351.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7718.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7351.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7351.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7351.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11443.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11443.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7351.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7351.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12620.81,,facility
PSYCHOSES,885,MS-DRG,120,RC,,,,inpatient,,,,,21220.12,,,,,,,case rate,,15617.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15617.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22440.39,,,,,,,case rate,,23668.78,,,,,,,case rate,,19926.21,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15617.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14836.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15617.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15617.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15617.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16398.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15617.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15617.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15617.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16398.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15617.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15617.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15617.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21460.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21460.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15617.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15617.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23668.78,,facility
SEIZURES WITHOUT MCC,101,MS-DRG,120,RC,,,,inpatient,,,,,13875.27,,,,,,,case rate,,10261.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10261.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14938.36,,,,,,,case rate,,15756.09,,,,,,,case rate,,13264.7,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10261.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9748.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10261.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10261.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10261.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10775.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10261.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10261.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10261.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10775.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10261.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10261.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10261.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14286.18,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14286.18,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10261.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10261.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15756.09,,facility
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,120,RC,,,,inpatient,,,,,12291.59,,,,,,,case rate,,9799.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9799.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14898.95,,,,,,,case rate,,15714.52,,,,,,,case rate,,13229.7,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9799.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9309.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9799.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9799.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9799.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10289.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9799.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9799.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9799.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10289.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9799.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9799.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9799.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14248.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14248.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9799.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9799.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15714.52,,facility
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,120,RC,,,,inpatient,,,,,35205.28,,,,,,,case rate,,27131.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27131.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39147.51,,,,,,,case rate,,41290.45,,,,,,,case rate,,34761.5,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,27131.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25774.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27131.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27131.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27131.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28487.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27131.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27131.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27131.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28487.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27131.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27131.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27131.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37438.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37438.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27131.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27131.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,41290.45,,facility
HAND PROCEDURES FOR INJURIES,906,MS-DRG,120,RC,,,,inpatient,,,,,32855.36,,,,,,,case rate,,21767.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21767.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30901.52,,,,,,,case rate,,32593.08,,,,,,,case rate,,27439.37,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21767.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20679.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21767.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21767.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21767.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22856.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21767.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21767.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21767.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22856.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21767.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21767.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21767.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29552.41,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29552.41,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21767.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21767.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32855.36,,facility
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,120,RC,,,,inpatient,,,,,26809.67,,,,,,,case rate,,19523.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19523.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30738.93,,,,,,,case rate,,32421.59,,,,,,,case rate,,27295,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19523.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18547.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19523.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19523.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19523.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19523.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19523.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19523.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19523.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19523.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19523.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29396.92,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29396.92,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19523.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19523.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32421.59,,facility
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,120,RC,,,,inpatient,,,,,52615.24,,,,,,,case rate,,36683.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36683.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,53637.52,,,,,,,case rate,,56573.65,,,,,,,case rate,,47628.08,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,36683.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,34849.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36683.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36683.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36683.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,38517.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,36683.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36683.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36683.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,38517.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,36683.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36683.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36683.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51295.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,51295.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36683.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36683.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,56573.65,,facility
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,120,RC,,,,inpatient,,,,,35525.93,,,,,,,case rate,,25527.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25527.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38055.38,,,,,,,case rate,,40138.54,,,,,,,case rate,,33791.73,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25527.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24251.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25527.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25527.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25527.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26803.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25527.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25527.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25527.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26803.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25527.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25527.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25527.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36393.94,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36393.94,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25527.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25527.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,40138.54,,facility
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,120,RC,,,,inpatient,,,,,11746.64,,,,,,,case rate,,8928.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8928.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12901.91,,,,,,,case rate,,13608.16,,,,,,,case rate,,11456.4,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8928.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8482.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8928.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8928.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8928.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9375.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8928.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8928.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8928.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9375.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8928.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8928.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8928.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12338.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12338.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8928.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8928.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13608.16,,facility
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,120,RC,,,,inpatient,,,,,20172.36,,,,,,,case rate,,14803.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14803.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22103.72,,,,,,,case rate,,23313.68,,,,,,,case rate,,19627.26,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14803.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14063.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14803.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14803.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14803.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15544.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14803.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14803.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14803.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15544.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14803.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14803.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14803.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21138.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21138.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14803.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14803.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23313.68,,facility
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,120,RC,,,,inpatient,,,,,33913.65,,,,,,,case rate,,23573.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23573.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37405.02,,,,,,,case rate,,39452.59,,,,,,,case rate,,33214.24,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23573.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22394.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23573.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23573.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23573.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24752.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23573.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23573.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23573.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24752.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23573.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23573.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23573.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35771.99,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35771.99,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23573.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23573.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,39452.59,,facility
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,120,RC,,,,inpatient,,,,,25356.96,,,,,,,case rate,,18588.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18588.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26822.04,,,,,,,case rate,,28290.29,,,,,,,case rate,,23816.96,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18588.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17658.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18588.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18588.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18588.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19517.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18588.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18588.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18588.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19517.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18588.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18588.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18588.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25651.04,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25651.04,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18588.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18588.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28290.29,,facility
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,120,RC,,,,inpatient,,,,,21902.06,,,,,,,case rate,,16396.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16396.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23269.75,,,,,,,case rate,,24543.54,,,,,,,case rate,,20662.65,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16396.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15577.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16396.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16396.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16396.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17216.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16396.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16396.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16396.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17216.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16396.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16396.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16396.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22253.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22253.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16396.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16396.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24543.54,,facility
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,120,RC,,,,inpatient,,,,,80090.29,,,,,,,case rate,,59681.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,59681.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,85365.11,,,,,,,case rate,,90038.02,,,,,,,case rate,,75800.98,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,59681.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,56697.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59681.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59681.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59681.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,62665.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,59681.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59681.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,59681.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62665.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,59681.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59681.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59681.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,81638.22,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,81638.22,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,59681.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59681.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,90038.02,,facility
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,120,RC,,,,inpatient,,,,,11206.2,,,,,,,case rate,,8304.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8304.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12003.57,,,,,,,case rate,,12660.65,,,,,,,case rate,,10658.71,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8304.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7889.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8304.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8304.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8304.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8719.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8304.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8304.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8304.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8719.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8304.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8304.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8304.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11479.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11479.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8304.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8304.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12660.65,,facility
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,120,RC,,,,inpatient,,,,,48099.04,,,,,,,case rate,,34628.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34628.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,48753.32,,,,,,,case rate,,51422.09,,,,,,,case rate,,43291.09,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,34628.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32897.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34628.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34628.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34628.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36360.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34628.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34628.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34628.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36360.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34628.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34628.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34628.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46624.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46624.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34628.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34628.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,51422.09,,facility
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,120,RC,,,,inpatient,,,,,61868.93,,,,,,,case rate,,46147.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46147.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,66427.75,,,,,,,case rate,,70064.03,,,,,,,case rate,,58985.32,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,46147.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,43840.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46147.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46147.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46147.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48454.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46147.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46147.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46147.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,48454.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46147.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46147.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46147.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,63527.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,63527.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46147.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46147.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,70064.03,,facility
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,120,RC,,,,inpatient,,,,,31785.02,,,,,,,case rate,,23657.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23657.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34471.88,,,,,,,case rate,,36358.88,,,,,,,case rate,,30609.72,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23657.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22475.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23657.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23657.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23657.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24840.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23657.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23657.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23657.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24840.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23657.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23657.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23657.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32966.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32966.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23657.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23657.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36358.88,,facility
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,120,RC,,,,inpatient,,,,,25447.28,,,,,,,case rate,,17889.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17889.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26449.24,,,,,,,case rate,,27897.08,,,,,,,case rate,,23485.92,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17889.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16994.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17889.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17889.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17889.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18783.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17889.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17889.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17889.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18783.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17889.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17889.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17889.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25294.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25294.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17889.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17889.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27897.08,,facility
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,120,RC,,,,inpatient,,,,,33827.84,,,,,,,case rate,,25699.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25699.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34816.76,,,,,,,case rate,,36722.64,,,,,,,case rate,,30915.96,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25699.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24414.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25699.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25699.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25699.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26984.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25699.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25699.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25699.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26984.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25699.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25699.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25699.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33296.72,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33296.72,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25699.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25699.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36722.64,,facility
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,120,RC,,,,inpatient,,,,,20508.06,,,,,,,case rate,,15514.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15514.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23072.67,,,,,,,case rate,,24335.68,,,,,,,case rate,,20487.66,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15514.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14739.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15514.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15514.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15514.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16290.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15514.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15514.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15514.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16290.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15514.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15514.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15514.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22065.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22065.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15514.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15514.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24335.68,,facility
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,120,RC,,,,inpatient,,,,,43877.89,,,,,,,case rate,,31585.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31585.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49173.75,,,,,,,case rate,,51865.53,,,,,,,case rate,,43664.42,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,31585.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30006.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31585.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31585.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31585.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33164.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31585.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31585.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31585.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33164.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31585.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31585.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31585.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,47026.91,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47026.91,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31585.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31585.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,51865.53,,facility
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,120,RC,,,,inpatient,,,,,30568,,,,,,,case rate,,31771.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31771.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42510.94,,,,,,,case rate,,44838,,,,,,,case rate,,37748.1,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,31771.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30183.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31771.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31771.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31771.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33360.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31771.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31771.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31771.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33360.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31771.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31771.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31771.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40654.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40654.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31771.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31771.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,44838,,facility
SKIN ULCERS WITH MCC,592,MS-DRG,120,RC,,,,inpatient,,,,,30955.54,,,,,,,case rate,,21453.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21453.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34325.71,,,,,,,case rate,,36204.71,,,,,,,case rate,,30479.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21453.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20380.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21453.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21453.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21453.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22526.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21453.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21453.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21453.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22526.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21453.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21453.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21453.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32827.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32827.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21453.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21453.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36204.71,,facility
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,120,RC,,,,inpatient,,,,,29213.79,,,,,,,case rate,,22158.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22158.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32220.28,,,,,,,case rate,,33984.03,,,,,,,case rate,,28610.39,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22158.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21050.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22158.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22158.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22158.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23266,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22158.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22158.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22158.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23266,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22158.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22158.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22158.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30813.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30813.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22158.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22158.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,33984.03,,facility
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,120,RC,,,,inpatient,,,,,52708.57,,,,,,,case rate,,39121.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39121.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,61129.69,,,,,,,case rate,,64475.95,,,,,,,case rate,,54280.84,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,39121.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37165.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39121.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39121.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39121.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41077.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39121.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39121.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39121.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41077.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39121.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39121.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39121.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58460.87,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,58460.87,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39121.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39121.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,64475.95,,facility
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,120,RC,,,,inpatient,,,,,29078.31,,,,,,,case rate,,20749.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20749.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32591.44,,,,,,,case rate,,34375.51,,,,,,,case rate,,28939.96,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20749.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19711.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20749.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20749.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20749.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21786.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20749.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20749.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20749.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21786.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20749.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20749.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20749.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31168.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31168.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20749.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20749.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,34375.51,,facility
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,120,RC,,,,inpatient,,,,,27371.18,,,,,,,case rate,,20290.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20290.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29402.1,,,,,,,case rate,,31011.58,,,,,,,case rate,,26107.94,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20290.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19276.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20290.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20290.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20290.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21305.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20290.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20290.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20290.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21305.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20290.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20290.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20290.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28118.45,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28118.45,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20290.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20290.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,31011.58,,facility
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,120,RC,,,,inpatient,,,,,16503.7,,,,,,,case rate,,12093.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12093.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 3.00 + Fixed Amount 8669.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,7842,,,,,,,case rate,,8095,,,,,,,case rate,,17763.55,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12093.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11488.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12093.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12093.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12093.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12698.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12093.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12093.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12093.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2122,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1804,,,,,,,per diem,,12698.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12093.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12093.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12093.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 2.00 + Fixed Amount 11638.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Outlier Per Diem Second Dollar + Days Threshold 2.00 + Fixed Amount 13781.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,12093.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12093.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17763.55,,facility
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,120,RC,,,,inpatient,,,,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,123145.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,123145.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,123145.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,116988.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,123145.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,123145.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,123145.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,129303.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,123145.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,123145.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,123145.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,129303.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,123145.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123145.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,123145.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,123145.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,123145.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,129303.13,,facility
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,120,RC,,,,inpatient,,,,,11251.36,,,,,,,case rate,,8300.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8300.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12115.25,,,,,,,case rate,,12778.44,,,,,,,case rate,,10757.88,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8300.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7885.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8300.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8300.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8300.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8715.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8300.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8300.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8300.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8715.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8300.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8300.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8300.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11586.32,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11586.32,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8300.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8300.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12778.44,,facility
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,120,RC,,,,inpatient,,,,,16598.54,,,,,,,case rate,,13136,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13136,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18213.11,,,,,,,case rate,,19210.1,,,,,,,case rate,,16172.55,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13136,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12479.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13136,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13136,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13136,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13792.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13136,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13136,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13136,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13792.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13136,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13136,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13136,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17417.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17417.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13136,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13136,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,19210.1,,facility
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,120,RC,,,,inpatient,,,,,25688.15,,,,,,,case rate,,18644.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18644.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27950.3,,,,,,,case rate,,29480.31,,,,,,,case rate,,24818.81,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18644.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17712.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18644.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18644.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18644.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19576.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18644.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18644.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18644.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19576.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18644.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18644.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18644.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26730.04,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26730.04,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18644.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18644.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29480.31,,facility
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,120,RC,,,,inpatient,,,,,87648.9,,,,,,,case rate,,64038.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,64038.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,99304.95,,,,,,,case rate,,104740.94,,,,,,,case rate,,88179.03,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,64038.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,60837.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64038.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64038.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64038.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,67240.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64038.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64038.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,64038.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,67240.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64038.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64038.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64038.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,94969.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,94969.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,64038.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64038.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,104740.94,,facility
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,120,RC,,,,inpatient,,,,,29523.9,,,,,,,case rate,,23015.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23015.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32744.18,,,,,,,case rate,,34536.6,,,,,,,case rate,,29075.59,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23015.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21864.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23015.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23015.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23015.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24166.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23015.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23015.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23015.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24166.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23015.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23015.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23015.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31314.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31314.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23015.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23015.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,34536.6,,facility
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,120,RC,,,,inpatient,,,,,12978.05,,,,,,,case rate,,9953.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9953.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15122.3,,,,,,,case rate,,15950.1,,,,,,,case rate,,13428.03,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9953.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9455.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9953.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9953.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9953.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10450.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9953.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9953.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9953.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10450.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9953.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9953.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9953.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14462.08,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14462.08,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9953.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9953.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15950.1,,facility
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,120,RC,,,,inpatient,,,,,82858.72,,,,,,,case rate,,61407.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,61407.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,61407.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,58337.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61407.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61407.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61407.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,64478.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,61407.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61407.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,61407.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,64478.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,61407.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,61407.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61407.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,61407.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,61407.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,82858.72,,facility
DIABETES WITHOUT CC/MCC,639,MS-DRG,120,RC,,,,inpatient,,,,,9432.84,,,,,,,case rate,,7212.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7212.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10223.32,,,,,,,case rate,,10782.94,,,,,,,case rate,,9077.92,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7212.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6851.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7212.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7212.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7212.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7572.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7212.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7212.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7212.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7572.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7212.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7212.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7212.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9776.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9776.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7212.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7212.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,10782.94,,facility
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,120,RC,,,,inpatient,,,,,46194.7,,,,,,,case rate,,32736.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32736.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50500.72,,,,,,,case rate,,53265.15,,,,,,,case rate,,44842.73,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,32736.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31099.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32736.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32736.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32736.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,34373.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32736.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32736.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32736.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34373.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32736.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32736.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32736.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48295.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,48295.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32736.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32736.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,53265.15,,facility
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,120,RC,,,,inpatient,,,,,16572.95,,,,,,,case rate,,11953.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11953.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16487.05,,,,,,,case rate,,17389.56,,,,,,,case rate,,14639.87,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11953.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11355.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11953.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11953.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11953.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12551.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11953.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11953.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11953.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12551.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11953.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11953.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11953.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15767.25,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15767.25,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11953.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11953.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17389.56,,facility
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,120,RC,,,,inpatient,,,,,16241.76,,,,,,,case rate,,12740.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12740.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19687.89,,,,,,,case rate,,20765.61,,,,,,,case rate,,17482.1,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12740.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12103.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12740.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12740.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12740.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13377.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12740.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12740.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12740.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13377.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12740.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12740.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12740.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18828.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18828.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12740.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12740.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20765.61,,facility
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,120,RC,,,,inpatient,,,,,20381.61,,,,,,,case rate,,15288.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15288.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22264.66,,,,,,,case rate,,23483.44,,,,,,,case rate,,19770.17,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15288.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14523.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15288.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15288.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15288.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16052.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15288.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15288.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15288.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16052.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15288.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15288.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15288.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21292.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21292.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15288.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15288.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23483.44,,facility
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,120,RC,,,,inpatient,,,,,24130.06,,,,,,,case rate,,18944.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18944.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26940.29,,,,,,,case rate,,28415.01,,,,,,,case rate,,23921.95,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18944.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17997.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18944.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18944.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18944.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19892.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18944.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18944.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18944.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19892.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18944.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18944.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18944.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25764.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25764.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18944.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18944.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28415.01,,facility
PLEURAL EFFUSION WITH MCC,186,MS-DRG,120,RC,,,,inpatient,,,,,23785.32,,,,,,,case rate,,17370.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17370.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25490.14,,,,,,,case rate,,26885.48,,,,,,,case rate,,22634.27,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17370.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16501.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17370.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17370.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17370.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18238.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17370.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17370.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17370.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18238.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17370.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17370.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17370.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24377.28,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24377.28,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17370.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17370.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26885.48,,facility
OSTEOMYELITIS WITH CC,540,MS-DRG,120,RC,,,,inpatient,,,,,19481.38,,,,,,,case rate,,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21320.34,,,,,,,case rate,,22487.42,,,,,,,case rate,,18931.65,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13802.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15255.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15255.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20389.53,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20389.53,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22487.42,,facility
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,120,RC,,,,inpatient,,,,,56785.19,,,,,,,case rate,,42325.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42325.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,63236.76,,,,,,,case rate,,66698.36,,,,,,,case rate,,56151.84,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,42325.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,40209.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42325.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42325.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42325.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44441.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42325.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42325.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42325.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,44441.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42325.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42325.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42325.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60475.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,60475.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42325.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42325.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,66698.36,,facility
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,120,RC,,,,inpatient,,,,,77529.61,,,,,,,case rate,,58238.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,58238.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,58238.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,55326.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58238.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58238.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58238.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,61150.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,58238.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58238.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,58238.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,61150.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,58238.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58238.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58238.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,58238.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58238.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,77529.61,,facility
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,120,RC,,,,inpatient,,,,,27237.2,,,,,,,case rate,,20439.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20439.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30423.61,,,,,,,case rate,,32089.01,,,,,,,case rate,,27015.01,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20439.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19417.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20439.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20439.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20439.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21461.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20439.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20439.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20439.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21461.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20439.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20439.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20439.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29095.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29095.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20439.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20439.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32089.01,,facility
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,120,RC,,,,inpatient,,,,,83207.97,,,,,,,case rate,,57850.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,57850.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,100860.21,,,,,,,case rate,,106381.33,,,,,,,case rate,,89560.04,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,57850.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,54958.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57850.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57850.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57850.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,60743.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,57850.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57850.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,57850.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,60743.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,57850.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57850.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57850.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,96456.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,96456.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,57850.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57850.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,106381.33,,facility
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,120,RC,,,,inpatient,,,,,25045.34,,,,,,,case rate,,18147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27406.7,,,,,,,case rate,,28906.95,,,,,,,case rate,,24336.11,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17239.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19054.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19054.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26210.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26210.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28906.95,,facility
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,120,RC,,,,inpatient,,,,,15495.08,,,,,,,case rate,,11545.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11545.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17117.69,,,,,,,case rate,,18054.72,,,,,,,case rate,,15199.86,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11545.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10967.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11545.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11545.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11545.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12122.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11545.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11545.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11545.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12122.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11545.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11545.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11545.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16370.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16370.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11545.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11545.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18054.72,,facility
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,120,RC,,,,inpatient,,,,,12002.55,,,,,,,case rate,,9445.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9445.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13163.03,,,,,,,case rate,,13883.58,,,,,,,case rate,,11688.27,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9445.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8973.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9445.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9445.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9445.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9918.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9445.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9445.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9445.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9918.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9445.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9445.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9445.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12588.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12588.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9445.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9445.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13883.58,,facility
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,120,RC,,,,inpatient,,,,,25608.36,,,,,,,case rate,,18712.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18712.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28211.43,,,,,,,case rate,,29755.73,,,,,,,case rate,,25050.68,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18712.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17777.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18712.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18712.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18712.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19648.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18712.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18712.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18712.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19648.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18712.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18712.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18712.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26979.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26979.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18712.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18712.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29755.73,,facility
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,120,RC,,,,inpatient,,,,,27932.7,,,,,,,case rate,,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29786.4,,,,,,,case rate,,31416.91,,,,,,,case rate,,26449.19,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19919.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22016.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22016.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28485.97,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28485.97,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,31416.91,,facility
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,120,RC,,,,inpatient,,,,,22955.84,,,,,,,case rate,,17469.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17469.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26792.48,,,,,,,case rate,,28259.11,,,,,,,case rate,,23790.71,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17469.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16596.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17469.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17469.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17469.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18343.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17469.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17469.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17469.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18343.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17469.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17469.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17469.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25622.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25622.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17469.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17469.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28259.11,,facility
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,120,RC,,,,inpatient,,,,,29701.54,,,,,,,case rate,,20029.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20029.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32640.71,,,,,,,case rate,,34427.48,,,,,,,case rate,,28983.71,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20029.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19028.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20029.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20029.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20029.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21031.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20029.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20029.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20029.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21031.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20029.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20029.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20029.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31215.67,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31215.67,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20029.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20029.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,34427.48,,facility
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,120,RC,,,,inpatient,,,,,28382.81,,,,,,,case rate,,22225.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22225.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30697.87,,,,,,,case rate,,32378.28,,,,,,,case rate,,27258.54,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22225.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21114.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22225.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22225.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22225.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23336.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22225.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22225.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22225.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23336.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22225.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22225.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22225.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29357.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29357.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22225.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22225.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32378.28,,facility
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,120,RC,,,,inpatient,,,,,13434.19,,,,,,,case rate,,10448.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10448.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14738,,,,,,,case rate,,15544.76,,,,,,,case rate,,13086.78,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10448.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9925.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10448.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10448.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10448.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10970.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10448.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10448.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10448.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10970.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10448.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10448.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10448.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14094.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14094.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10448.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10448.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15544.76,,facility
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,120,RC,,,,inpatient,,,,,26732.89,,,,,,,case rate,,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30612.47,,,,,,,case rate,,32288.21,,,,,,,case rate,,27182.71,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19594.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21656.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21656.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29275.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29275.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20625.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32288.21,,facility
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,120,RC,,,,inpatient,,,,,27908.61,,,,,,,case rate,,21789.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21789.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30799.69,,,,,,,case rate,,32485.68,,,,,,,case rate,,27348.96,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21789.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20700.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21789.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21789.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21789.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22879.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21789.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21789.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21789.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22879.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21789.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21789.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21789.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29455.03,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29455.03,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21789.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21789.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32485.68,,facility
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,120,RC,,,,inpatient,,,,,53133.09,,,,,,,case rate,,37404.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37404.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52566.74,,,,,,,case rate,,55444.26,,,,,,,case rate,,46677.27,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,37404.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,35533.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37404.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37404.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37404.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,39274.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,37404.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37404.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37404.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39274.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,37404.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37404.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37404.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50271.76,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50271.76,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37404.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37404.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,55444.26,,facility
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,120,RC,,,,inpatient,,,,,19129.12,,,,,,,case rate,,13696.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13696.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19663.26,,,,,,,case rate,,20739.63,,,,,,,case rate,,17460.23,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13696.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13011.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13696.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13696.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13696.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14381.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13696.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13696.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13696.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14381.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13696.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13696.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13696.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18804.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18804.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13696.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13696.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20739.63,,facility
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,120,RC,,,,inpatient,,,,,75018.6,,,,,,,case rate,,54096.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,54096.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,82750.57,,,,,,,case rate,,87280.36,,,,,,,case rate,,73479.36,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,54096.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51391.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54096.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54096.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54096.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,56801.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,54096.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54096.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,54096.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,56801.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,54096.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,54096.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54096.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,79137.82,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,79137.82,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,54096.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54096.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,87280.36,,facility
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,120,RC,,,,inpatient,,,,,22848.96,,,,,,,case rate,,18143.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18143.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27020.76,,,,,,,case rate,,28499.89,,,,,,,case rate,,23993.41,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18143.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17236.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18143.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18143.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18143.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19051.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18143.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18143.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18143.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19051.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18143.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18143.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18143.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25841.08,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25841.08,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18143.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18143.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28499.89,,facility
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,120,RC,,,,inpatient,,,,,10832.86,,,,,,,case rate,,8388.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8388.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11343.37,,,,,,,case rate,,11964.31,,,,,,,case rate,,10072.48,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8388.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7968.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8388.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8388.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8388.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8807.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8388.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8388.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8388.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8807.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8388.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8388.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8388.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10848.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10848.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8388.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8388.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,11964.31,,facility
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,120,RC,,,,inpatient,,,,,18141.58,,,,,,,case rate,,13562.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13562.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19809.42,,,,,,,case rate,,20893.8,,,,,,,case rate,,17590.01,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13562.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12884.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13562.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13562.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13562.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14241.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13562.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13562.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13562.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14241.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13562.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13562.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13562.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18944.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18944.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13562.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13562.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20893.8,,facility
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,120,RC,,,,inpatient,,,,,32152.33,,,,,,,case rate,,24534.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24534.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35325.87,,,,,,,case rate,,37259.62,,,,,,,case rate,,31368.03,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,24534.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23307.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24534.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24534.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24534.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25761.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24534.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24534.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24534.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25761.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24534.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24534.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24534.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33783.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33783.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24534.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24534.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,37259.62,,facility
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,120,RC,,,,inpatient,,,,,58865.66,,,,,,,case rate,,45189.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37275,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,45189.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,64000.43,,,,,,,case rate,,67503.83,,,,,,,case rate,,56829.95,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,45189.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,42930.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45189.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45189.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45189.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47449.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,45189.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45189.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,45189.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,47449.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,45189.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45189.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45189.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,61206.28,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,61206.28,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45189.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45189.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,67503.83,,facility
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,120,RC,,,,inpatient,,,,,22721,,,,,,,case rate,,16729.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16729.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24501.47,,,,,,,case rate,,25842.69,,,,,,,case rate,,21756.38,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16729.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15893.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16729.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16729.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16729.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17566.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16729.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16729.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16729.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17566.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16729.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16729.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16729.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23431.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23431.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16729.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16729.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25842.69,,facility
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,120,RC,,,,inpatient,,,,,127566.09,,,,,,,case rate,,91837.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,91837.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,133275.93,,,,,,,case rate,,140571.49,,,,,,,case rate,,118343.96,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,91837.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,87245.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,91837.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,91837.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,91837.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,96429.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,91837.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,91837.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,91837.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,96429.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,91837.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,91837.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,91837.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,127457.33,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,127457.33,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,91837.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,91837.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,140571.49,,facility
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,120,RC,,,,inpatient,,,,,37696.72,,,,,,,case rate,,25656.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25656.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39316.66,,,,,,,case rate,,41468.87,,,,,,,case rate,,34911.7,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25656.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24373.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25656.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25656.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25656.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26939.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25656.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25656.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25656.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26939.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25656.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25656.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25656.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37600.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37600.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25656.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25656.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,41468.87,,facility
AFTERCARE WITH CC/MCC,949,MS-DRG,120,RC,,,,inpatient,,,,,16243.27,,,,,,,case rate,,13373.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13373.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17015.87,,,,,,,case rate,,17947.32,,,,,,,case rate,,15109.45,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13373.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12704.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13373.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13373.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13373.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14042.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13373.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13373.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13373.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14042.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13373.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13373.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13373.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16272.99,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16272.99,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13373.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13373.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17947.32,,facility
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,120,RC,,,,inpatient,,,,,31470.39,,,,,,,case rate,,23527.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23527.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34949.79,,,,,,,case rate,,36862.95,,,,,,,case rate,,31034.08,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23527.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22351.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23527.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23527.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23527.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24704.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23527.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23527.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23527.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24704.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23527.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23527.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23527.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33423.94,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33423.94,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23527.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23527.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36862.95,,facility
PROSTATECTOMY WITH CC,666,MS-DRG,120,RC,,,,inpatient,,,,,24798.45,,,,,,,case rate,,19437.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19437.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28204.86,,,,,,,case rate,,29748.8,,,,,,,case rate,,25044.84,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19437.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18466.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19437.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19437.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19437.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20409.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19437.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19437.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19437.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20409.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19437.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19437.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19437.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26973.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26973.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19437.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19437.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29748.8,,facility
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,120,RC,,,,inpatient,,,,,28795.29,,,,,,,case rate,,19921.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19921.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30569.77,,,,,,,case rate,,32243.17,,,,,,,case rate,,27144.8,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19921.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18925.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19921.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19921.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19921.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20917.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19921.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19921.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19921.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20917.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19921.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19921.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19921.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29235.15,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29235.15,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19921.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19921.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32243.17,,facility
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,120,RC,,,,inpatient,,,,,16904.14,,,,,,,case rate,,12863.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12863.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18300.15,,,,,,,case rate,,19301.9,,,,,,,case rate,,16249.84,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12863.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12220.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12863.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12863.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12863.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13507.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12863.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12863.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12863.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13507.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12863.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12863.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12863.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17501.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17501.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12863.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12863.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,19301.9,,facility
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,120,RC,,,,inpatient,,,,,34244.84,,,,,,,case rate,,26386.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26386.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37764.69,,,,,,,case rate,,39831.94,,,,,,,case rate,,33533.61,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,26386.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25067.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26386.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26386.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26386.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27706.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26386.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26386.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26386.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27706.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26386.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26386.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26386.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36115.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36115.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26386.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26386.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,39831.94,,facility
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,120,RC,,,,inpatient,,,,,12207.29,,,,,,,case rate,,9232.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9232.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12926.54,,,,,,,case rate,,13634.15,,,,,,,case rate,,11478.28,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9232.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8770.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9232.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9232.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9232.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9694.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9232.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9232.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9232.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9694.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9232.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9232.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9232.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12362.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12362.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9232.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9232.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13634.15,,facility
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,120,RC,,,,inpatient,,,,,10090.7,,,,,,,case rate,,7863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11234.97,,,,,,,case rate,,11849.98,,,,,,,case rate,,9976.23,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7470.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8256.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8256.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10744.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10744.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,11849.98,,facility
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,120,RC,,,,inpatient,,,,,15984.34,,,,,,,case rate,,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 10230.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,11529,,,,,,,case rate,,12984,,,,,,,case rate,,15328.19,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11954.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17858,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17858,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13212.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2122,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1804,,,,,,,per diem,,13212.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 14228.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 16055.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12583.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17858,,facility
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,120,RC,,,,inpatient,,,,,19395.57,,,,,,,case rate,,15575.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15575.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21077.28,,,,,,,case rate,,22231.05,,,,,,,case rate,,18715.82,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15575.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14796.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15575.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15575.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15575.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16354.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15575.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15575.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15575.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16354.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15575.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15575.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15575.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20157.08,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20157.08,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15575.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15575.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22231.05,,facility
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,120,RC,,,,inpatient,,,,,13620.86,,,,,,,case rate,,10186.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10186.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14936.72,,,,,,,case rate,,15754.36,,,,,,,case rate,,13263.24,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10186.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9676.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10186.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10186.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10186.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10695.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10186.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10186.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10186.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10695.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10186.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10186.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10186.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14284.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14284.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10186.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10186.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15754.36,,facility
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,120,RC,,,,inpatient,,,,,42277.65,,,,,,,case rate,,31910.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31910.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47419.77,,,,,,,case rate,,50015.54,,,,,,,case rate,,42106.95,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,31910.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30315.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31910.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31910.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31910.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33506.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31910.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31910.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31910.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33506.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31910.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31910.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31910.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45349.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45349.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31910.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31910.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,50015.54,,facility
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,120,RC,,,,inpatient,,,,,121351.8,,,,,,,case rate,,85757.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,85757.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,138813.77,,,,,,,case rate,,146412.47,,,,,,,case rate,,123261.35,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,85757.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,81469.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,85757.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,85757.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,85757.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,90044.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,85757.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,85757.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,85757.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,90044.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,85757.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,85757.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,85757.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,132753.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,132753.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,85757.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,85757.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,146412.47,,facility
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,120,RC,,,,inpatient,,,,,10915.66,,,,,,,case rate,,8316.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24849,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8316.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11793.36,,,,,,,case rate,,12438.93,,,,,,,case rate,,10472.05,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8316.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7900.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8316.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8316.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8316.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8732.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8316.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8316.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8316.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8732.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8316.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8316.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8316.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11278.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11278.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8316.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8316.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24849,,facility
NORMAL NEWBORN,795,MS-DRG,120,RC,,,,inpatient,,,,,3007.79,,,,,,,case rate,,2645.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,2645.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1065,,,,,,,per diem,,1154,,,,,,,per diem,,2941.39,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,2645.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2513.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2645.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2645.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2645.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2777.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2645.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2645.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,2645.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,2777.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2645.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2645.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2645.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1872,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1830,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2645.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2645.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1065,5834,,facility
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,120,RC,,,,inpatient,,,,,20626.99,,,,,,,case rate,,15254.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15254.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21993.68,,,,,,,case rate,,23197.62,,,,,,,case rate,,19529.55,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15254.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14491.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15254.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15254.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15254.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16017.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15254.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15254.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15254.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16017.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15254.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15254.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15254.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21033.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21033.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15254.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15254.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23197.62,,facility
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,120,RC,,,,inpatient,,,,,30296.18,,,,,,,case rate,,20109.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20109.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31934.52,,,,,,,case rate,,33682.63,,,,,,,case rate,,28356.64,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20109.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19104.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20109.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20109.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20109.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21115.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20109.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20109.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20109.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21115.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20109.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20109.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20109.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30540.32,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30540.32,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20109.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20109.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,33682.63,,facility
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,120,RC,,,,inpatient,,,,,10211.13,,,,,,,case rate,,8996.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8996.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12226.92,,,,,,,case rate,,12896.23,,,,,,,case rate,,10857.04,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8996.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8546.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8996.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8996.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8996.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9445.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8996.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8996.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8996.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9445.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8996.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8996.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8996.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11693.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11693.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8996.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8996.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12896.23,,facility
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,120,RC,,,,inpatient,,,,,14146.24,,,,,,,case rate,,11939.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11939.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15741.45,,,,,,,case rate,,16603.14,,,,,,,case rate,,13977.81,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11939.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11342.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11939.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11939.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11939.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12536.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11939.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11939.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11939.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12536.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11939.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11939.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11939.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15054.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15054.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11939.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11939.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16603.14,,facility
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,120,RC,,,,inpatient,,,,,28566.47,,,,,,,case rate,,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30904.8,,,,,,,case rate,,32596.54,,,,,,,case rate,,27442.29,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19919.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22016.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22016.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29555.55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29555.55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20968.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32596.54,,facility
AICD GENERATOR PROCEDURES,245,MS-DRG,120,RC,,,,inpatient,,,,,73565.89,,,,,,,case rate,,49924.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49924.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,74419.18,,,,,,,case rate,,78492.91,,,,,,,case rate,,66081.41,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,49924.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47428.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49924.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49924.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49924.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52420.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49924.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49924.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49924.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,52420.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49924.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49924.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49924.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,71170.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,71170.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49924.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49924.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,78492.91,,facility
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,120,RC,,,,inpatient,,,,,79736.52,,,,,,,case rate,,58273.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,58273.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,86132.07,,,,,,,case rate,,90846.96,,,,,,,case rate,,76482,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,58273.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,55359.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58273.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58273.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58273.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,61187.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,58273.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58273.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,58273.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,61187.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,58273.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58273.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58273.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,82371.69,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,82371.69,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,58273.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58273.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,90846.96,,facility
RADIOTHERAPY,849,MS-DRG,120,RC,,,,inpatient,,,,,40210.74,,,,,,,case rate,,29843.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29843.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44200.86,,,,,,,case rate,,46620.43,,,,,,,case rate,,39248.69,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,29843.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28351.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29843.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29843.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29843.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31336.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29843.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29843.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29843.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31336.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29843.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29843.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29843.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42271.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42271.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29843.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29843.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,46620.43,,facility
URINARY STONES WITHOUT MCC,694,MS-DRG,120,RC,,,,inpatient,,,,,11763.2,,,,,,,case rate,,8951.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8951.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12854.28,,,,,,,case rate,,13557.93,,,,,,,case rate,,11414.11,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8951.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8504.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8951.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8951.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8951.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9399.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8951.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8951.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8951.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9399.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8951.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8951.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8951.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12293.09,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12293.09,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8951.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8951.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13557.93,,facility
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,120,RC,,,,inpatient,,,,,19031.27,,,,,,,case rate,,15443.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15443.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22962.64,,,,,,,case rate,,24219.62,,,,,,,case rate,,20389.95,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15443.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14671.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15443.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15443.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15443.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16215.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15443.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15443.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15443.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16215.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15443.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15443.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15443.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21960.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21960.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15443.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15443.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24219.62,,facility
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,120,RC,,,,inpatient,,,,,23622.74,,,,,,,case rate,,17208.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17208.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25651.08,,,,,,,case rate,,27055.23,,,,,,,case rate,,22777.19,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17208.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16348.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17208.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17208.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17208.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18069.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17208.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17208.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17208.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18069.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17208.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17208.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17208.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24531.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24531.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17208.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17208.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27055.23,,facility
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,120,RC,,,,inpatient,,,,,22993.48,,,,,,,case rate,,16955.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16955.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23961.16,,,,,,,case rate,,25272.8,,,,,,,case rate,,21276.6,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16955.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16107.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16955.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16955.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16955.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17802.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16955.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16955.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16955.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17802.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16955.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16955.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16955.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22915.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22915.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16955.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16955.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25272.8,,facility
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,120,RC,,,,inpatient,,,,,9580.37,,,,,,,case rate,,7513.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7513.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10633.89,,,,,,,case rate,,11216,,,,,,,case rate,,9442.49,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7513.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7137.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7513.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7513.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7513.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7889.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7513.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7513.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7513.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7889.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7513.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7513.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7513.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10169.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10169.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7513.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7513.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,11216,,facility
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,120,RC,,,,inpatient,,,,,67326,,,,,,,case rate,,49754.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49754.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,72523.97,,,,,,,case rate,,76493.95,,,,,,,case rate,,64398.53,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,49754.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47266.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49754.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49754.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49754.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52242,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49754.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49754.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49754.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,52242,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49754.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49754.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49754.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,69357.7,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,69357.7,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49754.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49754.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,76493.95,,facility
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,120,RC,,,,inpatient,,,,,26460.42,,,,,,,case rate,,22394.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22394.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30655.17,,,,,,,case rate,,32333.25,,,,,,,case rate,,27220.63,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22394.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21274.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22394.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22394.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22394.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23514.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22394.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22394.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22394.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23514.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22394.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22394.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22394.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29316.82,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29316.82,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22394.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22394.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32333.25,,facility
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,120,RC,,,,inpatient,,,,,32089.11,,,,,,,case rate,,23265.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23265.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33593.25,,,,,,,case rate,,35432.15,,,,,,,case rate,,29829.53,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23265.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22102.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23265.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23265.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23265.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24428.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23265.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23265.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23265.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24428.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23265.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23265.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23265.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32126.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32126.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23265.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23265.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,35432.15,,facility
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,120,RC,,,,inpatient,,,,,26162.35,,,,,,,case rate,,18704.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18704.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29134.4,,,,,,,case rate,,30729.23,,,,,,,case rate,,25870.24,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18704.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17769.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18704.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18704.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18704.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19639.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18704.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18704.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18704.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19639.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18704.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18704.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18704.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27862.44,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27862.44,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18704.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18704.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30729.23,,facility
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,120,RC,,,,inpatient,,,,,34813.88,,,,,,,case rate,,24132.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37275,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24132.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38607.19,,,,,,,case rate,,40720.56,,,,,,,case rate,,34281.72,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,24132.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22926.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24132.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24132.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24132.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25339.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24132.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24132.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24132.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25339.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24132.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24132.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24132.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36921.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36921.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24132.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24132.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,40720.56,,facility
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,018,MS-DRG,120,RC,,,,inpatient,,,,,567728.49,,,,,,,case rate,,468466.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,468466.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,605067.66,,,,,,,case rate,,638189.25,,,,,,,case rate,,537277.09,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,468466.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,445043.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,468466.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,468466.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,468466.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,491890.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,468466.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,468466.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,468466.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,491890.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,468466.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,468466.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,468466.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,468466.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,468466.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,638189.25,,facility
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,120,RC,,,,inpatient,,,,,65003.17,,,,,,,case rate,,45700.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,45700.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,74412.61,,,,,,,case rate,,78485.98,,,,,,,case rate,,66075.57,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,45700.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,43415.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45700.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45700.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45700.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47985.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,45700.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45700.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,45700.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,47985.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,45700.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45700.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45700.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,71163.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,71163.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45700.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45700.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,78485.98,,facility
FOOT PROCEDURES WITH MCC,503,MS-DRG,120,RC,,,,inpatient,,,,,39841.92,,,,,,,case rate,,30728.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30728.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44044.84,,,,,,,case rate,,46455.87,,,,,,,case rate,,39110.15,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,30728.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29191.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30728.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30728.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30728.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32264.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30728.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30728.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30728.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32264.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30728.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30728.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30728.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42121.92,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42121.92,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30728.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30728.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,46455.87,,facility
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,120,RC,,,,inpatient,,,,,24241.46,,,,,,,case rate,,16879.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16879.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26043.59,,,,,,,case rate,,27469.23,,,,,,,case rate,,23125.72,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16879.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16035.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16879.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16879.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16879.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17723.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16879.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16879.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16879.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17723.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16879.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16879.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16879.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24906.57,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24906.57,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16879.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16879.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27469.23,,facility
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,120,RC,,,,inpatient,,,,,20399.68,,,,,,,case rate,,15629.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15629.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21039.51,,,,,,,case rate,,22191.21,,,,,,,case rate,,18682.28,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15629.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14848.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15629.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15629.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15629.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16411.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15629.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15629.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15629.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16411.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15629.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15629.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15629.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20120.96,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20120.96,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15629.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15629.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22191.21,,facility
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,120,RC,,,,inpatient,,,,,13009.67,,,,,,,case rate,,10303.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10303.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14673.95,,,,,,,case rate,,15477.21,,,,,,,case rate,,13029.91,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10303.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9787.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10303.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10303.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10303.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10818.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10303.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10303.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10303.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10818.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10303.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10303.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10303.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14033.31,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14033.31,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10303.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10303.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15477.21,,facility
VEIN LIGATION AND STRIPPING,263,MS-DRG,120,RC,,,,inpatient,,,,,40376.33,,,,,,,case rate,,33614.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33614.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46398.26,,,,,,,case rate,,48938.11,,,,,,,case rate,,41199.89,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,33614.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31933.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33614.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33614.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33614.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,35294.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33614.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33614.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33614.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35294.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33614.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33614.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33614.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44372.59,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44372.59,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33614.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33614.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,48938.11,,facility
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,120,RC,,,,inpatient,,,,,322631.31,,,,,,,case rate,,230504.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,472889,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,230504.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,350143.29,,,,,,,case rate,,369310.24,,,,,,,case rate,,310913.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,230504.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,218979.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,230504.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,230504.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,230504.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,242030.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,230504.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,230504.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,230504.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,242030.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,230504.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,230504.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,230504.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,280816,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,334856.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,230504.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,230504.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,472889,,facility
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,120,RC,,,,inpatient,,,,,48007.21,,,,,,,case rate,,35537.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35537.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,51325.16,,,,,,,case rate,,54134.71,,,,,,,case rate,,45574.79,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,35537.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33760.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35537.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35537.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35537.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37314.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35537.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35537.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35537.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37314.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35537.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35537.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35537.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49084.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49084.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35537.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35537.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,54134.71,,facility
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,120,RC,,,,inpatient,,,,,10713.93,,,,,,,case rate,,8480.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8480.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12067.62,,,,,,,case rate,,12728.21,,,,,,,case rate,,10715.59,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8480.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8056.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8480.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8480.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8480.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8904.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8480.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8480.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8480.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8904.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8480.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8480.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8480.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11540.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11540.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8480.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8480.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12728.21,,facility
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,120,RC,,,,inpatient,,,,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62327.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62327.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,62327.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,59211.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62327.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62327.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62327.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,65444.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,62327.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62327.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62327.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,65444.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,62327.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62327.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62327.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62327.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62327.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,65444.17,,facility
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,120,RC,,,,inpatient,,,,,24351.35,,,,,,,case rate,,18174.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18174.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25885.93,,,,,,,case rate,,27302.94,,,,,,,case rate,,22985.72,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18174.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17265.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18174.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18174.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18174.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19082.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18174.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18174.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18174.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19082.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18174.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18174.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18174.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24755.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24755.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18174.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18174.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27302.94,,facility
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,120,RC,,,,inpatient,,,,,32418.79,,,,,,,case rate,,23078.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33101,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23078.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34381.55,,,,,,,case rate,,36263.61,,,,,,,case rate,,30529.51,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23078.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21924.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23078.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23078.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23078.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24232.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23078.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23078.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23078.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24232.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23078.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23078.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23078.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32880.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32880.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23078.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23078.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36263.61,,facility
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,120,RC,,,,inpatient,,,,,23109.4,,,,,,,case rate,,17115.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17115.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24575.38,,,,,,,case rate,,25920.64,,,,,,,case rate,,21822,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17115.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16259.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17115.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17115.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17115.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17971.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17115.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17115.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17115.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17971.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17115.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17115.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17115.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23502.46,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23502.46,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17115.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17115.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25920.64,,facility
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,120,RC,,,,inpatient,,,,,9997.36,,,,,,,case rate,,7701.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7701.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10819.47,,,,,,,case rate,,11411.73,,,,,,,case rate,,9607.28,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7701.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7316.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7701.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7701.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7701.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8086.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7701.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7701.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7701.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8086.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7701.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7701.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7701.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10347.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10347.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7701.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7701.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,11411.73,,facility
DYSEQUILIBRIUM,149,MS-DRG,120,RC,,,,inpatient,,,,,11252.86,,,,,,,case rate,,8625.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8625.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12230.21,,,,,,,case rate,,12899.69,,,,,,,case rate,,10859.96,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8625.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8194.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8625.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8625.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8625.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9056.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8625.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8625.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8625.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9056.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8625.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8625.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8625.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11696.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11696.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8625.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8625.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12899.69,,facility
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,120,RC,,,,inpatient,,,,,62635.18,,,,,,,case rate,,46248.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46248.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,68296.69,,,,,,,case rate,,72035.27,,,,,,,case rate,,60644.86,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,46248.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,43935.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46248.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46248.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46248.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48560.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46248.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46248.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46248.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,48560.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46248.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46248.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46248.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,65314.97,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,65314.97,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46248.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46248.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,72035.27,,facility
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,120,RC,,,,inpatient,,,,,10122.31,,,,,,,case rate,,7969.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7969.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10765.28,,,,,,,case rate,,11354.57,,,,,,,case rate,,9559.16,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7969.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7571.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7969.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7969.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7969.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8368.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7969.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7969.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7969.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8368.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7969.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7969.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7969.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10295.28,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10295.28,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7969.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7969.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,11354.57,,facility
ANGINA PECTORIS,311,MS-DRG,120,RC,,,,inpatient,,,,,10512.21,,,,,,,case rate,,8086.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8086.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11464.9,,,,,,,case rate,,12092.49,,,,,,,case rate,,10180.39,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8086.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7682.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8086.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8086.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8086.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8491.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8086.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8086.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8086.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8491.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8086.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8086.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8086.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10964.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10964.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8086.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8086.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12092.49,,facility
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,120,RC,,,,inpatient,,,,,26419.77,,,,,,,case rate,,19909.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19909.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28012.71,,,,,,,case rate,,29546.14,,,,,,,case rate,,24874.22,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19909.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18913.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19909.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19909.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19909.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20904.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19909.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19909.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19909.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20904.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19909.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19909.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19909.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26789.72,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26789.72,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19909.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19909.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29546.14,,facility
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,120,RC,,,,inpatient,,,,,24256.51,,,,,,,case rate,,18064.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18064.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26275.16,,,,,,,case rate,,27713.47,,,,,,,case rate,,23331.34,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18064.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17161.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18064.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18064.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18064.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18968.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18064.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18064.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18064.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18968.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18064.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18064.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18064.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25128.03,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25128.03,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18064.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18064.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27713.47,,facility
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,120,RC,,,,inpatient,,,,,34847,,,,,,,case rate,,26547.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26547.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36557.6,,,,,,,case rate,,38558.77,,,,,,,case rate,,32461.76,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,26547.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25219.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26547.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26547.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26547.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27874.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26547.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26547.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26547.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27874.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26547.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26547.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26547.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34961.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34961.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26547.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26547.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,38558.77,,facility
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,120,RC,,,,inpatient,,,,,38009.84,,,,,,,case rate,,33174.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33174.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42880.45,,,,,,,case rate,,45227.74,,,,,,,case rate,,38076.21,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,33174.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31515.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33174.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33174.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33174.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,34832.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33174.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33174.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33174.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34832.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,33174.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33174.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33174.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41008.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41008.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33174.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,33174.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,45227.74,,facility
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,120,RC,,,,inpatient,,,,,11376.31,,,,,,,case rate,,8658.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8658.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12604.65,,,,,,,case rate,,13294.63,,,,,,,case rate,,11192.45,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8658.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8225.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8658.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8658.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8658.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9090.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8658.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8658.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8658.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9090.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8658.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8658.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8658.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12054.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12054.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8658.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8658.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13294.63,,facility
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,120,RC,,,,inpatient,,,,,31798.56,,,,,,,case rate,,23332.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23332.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34575.34,,,,,,,case rate,,36468.01,,,,,,,case rate,,30701.59,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23332.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22166.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23332.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23332.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23332.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24499.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23332.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23332.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23332.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24499.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23332.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23332.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23332.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33065.84,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33065.84,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23332.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23332.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36468.01,,facility
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,120,RC,,,,inpatient,,,,,19092.99,,,,,,,case rate,,14706.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14706.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22274.51,,,,,,,case rate,,23493.83,,,,,,,case rate,,19778.92,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14706.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13971.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14706.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14706.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14706.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15441.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14706.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14706.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14706.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15441.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14706.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14706.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14706.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21302.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21302.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14706.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14706.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23493.83,,facility
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,120,RC,,,,inpatient,,,,,21397.76,,,,,,,case rate,,14514.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14514.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22389.48,,,,,,,case rate,,23615.08,,,,,,,case rate,,19881,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14514.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13788.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14514.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14514.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14514.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15240.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14514.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14514.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14514.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15240.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14514.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14514.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14514.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21411.99,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21411.99,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14514.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14514.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23615.08,,facility
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,120,RC,,,,inpatient,,,,,22222.71,,,,,,,case rate,,16474.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16474.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1843,,,,,,,per diem,,3909,,,,,,,per diem,,21727.21,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16474.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15651.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16474.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16474.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16474.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16474.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16474.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16474.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17298.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16474.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16474.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16474.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3796,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4352,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16474.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16474.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22222.71,,facility
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,120,RC,,,,inpatient,,,,,22410.89,,,,,,,case rate,,16787.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16787.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25301.27,,,,,,,case rate,,26686.27,,,,,,,case rate,,22466.57,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16787.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15947.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16787.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16787.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16787.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17626.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16787.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16787.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16787.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17626.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16787.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16787.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16787.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24196.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24196.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16787.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16787.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26686.27,,facility
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,120,RC,,,,inpatient,,,,,21706.36,,,,,,,case rate,,14543.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14543.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23256.61,,,,,,,case rate,,24529.68,,,,,,,case rate,,20650.99,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14543.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13816.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14543.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14543.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14543.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15270.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14543.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14543.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14543.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15270.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14543.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14543.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14543.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22241.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22241.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14543.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14543.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24529.68,,facility
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,120,RC,,,,inpatient,,,,,76694.11,,,,,,,case rate,,56892.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,56892.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,85179.53,,,,,,,case rate,,89842.29,,,,,,,case rate,,75636.19,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,56892.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,54048.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,56892.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,56892.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,56892.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,59737.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,56892.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,56892.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,56892.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,59737.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,56892.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,56892.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,56892.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,81460.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,81460.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,56892.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,56892.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,89842.29,,facility
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,120,RC,,,,inpatient,,,,,16198.1,,,,,,,case rate,,11346.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11346.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13117.05,,,,,,,case rate,,13835.08,,,,,,,case rate,,11647.44,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11346.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10779.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11346.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11346.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11346.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,1865.57,1865.57,1865.57,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,11914.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11346.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,1655.78,511.72,3096.66,20,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,11346.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11346.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11914.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11346.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11346.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11346.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12544.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12544.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11346.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11346.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16198.1,,facility
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,120,RC,,,,inpatient,,,,,39388.79,,,,,,,case rate,,29712.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29712.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45120.55,,,,,,,case rate,,47590.46,,,,,,,case rate,,40065.33,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,29712.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28227.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29712.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29712.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29712.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31198.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29712.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29712.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29712.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31198.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29712.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29712.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29712.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,43150.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,43150.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29712.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29712.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,47590.46,,facility
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,120,RC,,,,inpatient,,,,,12430.09,,,,,,,case rate,,8801.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8801.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13097.34,,,,,,,case rate,,13814.3,,,,,,,case rate,,11629.94,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8801.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8361.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8801.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8801.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8801.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9241.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8801.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8801.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8801.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9241.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8801.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8801.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8801.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12525.54,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12525.54,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8801.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8801.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13814.3,,facility
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,120,RC,,,,inpatient,,,,,12246.43,,,,,,,case rate,,10084.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10084.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14217.39,,,,,,,case rate,,14995.66,,,,,,,case rate,,12624.5,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10084.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9580,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10084.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10084.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10084.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10588.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10084.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10084.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10084.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10588.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10084.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10084.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10084.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13596.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13596.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10084.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10084.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14995.66,,facility
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,120,RC,,,,inpatient,,,,,12564.07,,,,,,,case rate,,9476.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9476.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13496.42,,,,,,,case rate,,14235.22,,,,,,,case rate,,11984.31,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9476.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9002.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9476.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9476.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9476.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9950.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9476.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9476.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9476.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9950.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9476.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9476.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9476.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12907.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12907.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9476.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9476.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14235.22,,facility
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,120,RC,,,,inpatient,,,,,9024.87,,,,,,,case rate,,7036.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7036.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10224.96,,,,,,,case rate,,10784.68,,,,,,,case rate,,9079.38,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7036.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6684.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7036.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7036.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7036.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7388.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7036.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7036.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7036.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7388.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7036.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7036.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7036.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9778.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9778.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7036.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7036.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,10784.68,,facility
EPISTAXIS WITHOUT MCC,151,MS-DRG,120,RC,,,,inpatient,,,,,11410.93,,,,,,,case rate,,8434.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8434.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12657.21,,,,,,,case rate,,13350.07,,,,,,,case rate,,11239.12,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8434.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8013.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8434.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8434.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8434.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8856.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8434.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8434.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8434.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8856.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8434.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8434.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8434.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12104.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12104.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8434.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8434.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13350.07,,facility
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,120,RC,,,,inpatient,,,,,21179.47,,,,,,,case rate,,15699.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15699.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23051.32,,,,,,,case rate,,24313.16,,,,,,,case rate,,20468.7,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15699.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14914.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15699.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15699.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15699.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16483.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15699.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15699.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15699.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16483.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15699.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15699.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15699.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22044.94,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22044.94,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15699.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15699.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24313.16,,facility
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,120,RC,,,,inpatient,,,,,9374.13,,,,,,,case rate,,7291.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7291.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10274.23,,,,,,,case rate,,10836.64,,,,,,,case rate,,9123.12,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7291.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6926.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7291.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7291.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7291.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7656,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7291.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7291.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7291.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7656,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7291.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7291.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7291.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9825.67,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9825.67,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7291.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7291.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,10836.64,,facility
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,120,RC,,,,inpatient,,,,,51641.24,,,,,,,case rate,,38284.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,38284.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55079.46,,,,,,,case rate,,58094.52,,,,,,,case rate,,48908.47,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,38284.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36369.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38284.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38284.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38284.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,40198.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,38284.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38284.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,38284.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40198.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,38284.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,38284.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38284.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52674.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52674.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38284.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38284.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,58094.52,,facility
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,120,RC,,,,inpatient,,,,,8535.62,,,,,,,case rate,,6505.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6505.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9689.57,,,,,,,case rate,,10219.98,,,,,,,case rate,,8603.97,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,6505.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6180.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6505.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6505.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6505.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6831.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6505.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6505.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6505.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6831.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6505.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6505.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6505.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9266.54,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9266.54,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6505.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6505.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,10219.98,,facility
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,120,RC,,,,inpatient,,,,,13946.03,,,,,,,case rate,,10376.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10376.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15480.32,,,,,,,case rate,,16327.72,,,,,,,case rate,,13745.94,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10376.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9857.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10376.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10376.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10376.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10895.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10376.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10376.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10376.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10895.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10376.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10376.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10376.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14804.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14804.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10376.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10376.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16327.72,,facility
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,120,RC,,,,inpatient,,,,,26362.56,,,,,,,case rate,,21359.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21359.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27378.78,,,,,,,case rate,,28877.51,,,,,,,case rate,,24311.32,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21359.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20291.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21359.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21359.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21359.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22427.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21359.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21359.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21359.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22427.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21359.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21359.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21359.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26183.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26183.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21359.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21359.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28877.51,,facility
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,120,RC,,,,inpatient,,,,,24664.47,,,,,,,case rate,,17407,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17407,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26329.35,,,,,,,case rate,,27770.63,,,,,,,case rate,,23379.47,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17407,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16536.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17407,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17407,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17407,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18277.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17407,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17407,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17407,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18277.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17407,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17407,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17407,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25179.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25179.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17407,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17407,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27770.63,,facility
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,120,RC,,,,inpatient,,,,,31560.71,,,,,,,case rate,,24076.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24076.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32144.74,,,,,,,case rate,,33904.35,,,,,,,case rate,,28543.31,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,24076.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22872.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24076.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24076.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24076.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25280.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24076.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24076.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24076.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25280.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24076.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24076.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24076.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30741.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30741.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24076.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24076.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,33904.35,,facility
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,120,RC,,,,inpatient,,,,,47781.4,,,,,,,case rate,,39803.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39803.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52804.87,,,,,,,case rate,,55695.43,,,,,,,case rate,,46888.72,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,39803.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37813.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39803.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39803.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39803.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41793.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39803.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39803.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39803.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41793.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39803.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39803.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39803.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50499.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50499.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39803.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39803.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,55695.43,,facility
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,120,RC,,,,inpatient,,,,,11587.06,,,,,,,case rate,,8662.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8662.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12535.68,,,,,,,case rate,,13221.88,,,,,,,case rate,,11131.2,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8662.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8229.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8662.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8662.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8662.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9095.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8662.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8662.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8662.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9095.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8662.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8662.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8662.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11988.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11988.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8662.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8662.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13221.88,,facility
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,120,RC,,,,inpatient,,,,,89493.02,,,,,,,case rate,,64891.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,64891.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1843,,,,,,,per diem,,3909,,,,,,,per diem,,87499.46,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,64891.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,61647.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64891.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64891.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64891.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,68136.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64891.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64891.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,64891.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,68136.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64891.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64891.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64891.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3796,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4352,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,64891.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64891.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,89493.02,,facility
ABORTION WITHOUT D&C,779,MS-DRG,120,RC,,,,inpatient,,,,,14072.48,,,,,,,case rate,,9597.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9597.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16245.63,,,,,,,case rate,,17134.92,,,,,,,case rate,,14425.5,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9597.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9117.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9597.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9597.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9597.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10077.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9597.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9597.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9597.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10077.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9597.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9597.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9597.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15536.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15536.38,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9597.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9597.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17134.92,,facility
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,120,RC,,,,inpatient,,,,,10507.69,,,,,,,case rate,,8074.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8074.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12213.79,,,,,,,case rate,,12882.37,,,,,,,case rate,,10845.38,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8074.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7671.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8074.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8074.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8074.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8478.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8074.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8074.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8074.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8478.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8074.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8074.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8074.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11680.55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11680.55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8074.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8074.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12882.37,,facility
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,120,RC,,,,inpatient,,,,,32149.32,,,,,,,case rate,,23574.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23574.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35371.86,,,,,,,case rate,,37308.12,,,,,,,case rate,,31408.87,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23574.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22395.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23574.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23574.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23574.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24753.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23574.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23574.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23574.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24753.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23574.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23574.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23574.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33827.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33827.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23574.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23574.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,37308.12,,facility
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,120,RC,,,,inpatient,,,,,35638.84,,,,,,,case rate,,26937.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26937.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40410.43,,,,,,,case rate,,42622.51,,,,,,,case rate,,35882.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,26937.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25590.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26937.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26937.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26937.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28284.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26937.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26937.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26937.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28284.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26937.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26937.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26937.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,38646.18,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38646.18,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26937.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26937.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,42622.51,,facility
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,120,RC,,,,inpatient,,,,,23350.26,,,,,,,case rate,,17686.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17686.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25705.28,,,,,,,case rate,,27112.39,,,,,,,case rate,,22825.31,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17686.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16802.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17686.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17686.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17686.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18570.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17686.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17686.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17686.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18570.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17686.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17686.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17686.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24583.03,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24583.03,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17686.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17686.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27112.39,,facility
SKIN ULCERS WITH CC,593,MS-DRG,120,RC,,,,inpatient,,,,,18406.53,,,,,,,case rate,,13336.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13336.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19870.19,,,,,,,case rate,,20957.89,,,,,,,case rate,,17643.97,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13336.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12669.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13336.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13336.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13336.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14003.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13336.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13336.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13336.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14003.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13336.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13336.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13336.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19002.69,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19002.69,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13336.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13336.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20957.89,,facility
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,120,RC,,,,inpatient,,,,,65137.15,,,,,,,case rate,,42682.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42682.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49794.54,,,,,,,case rate,,52520.3,,,,,,,case rate,,44215.66,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,42682.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,40548.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42682.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42682.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42682.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44817.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42682.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42682.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42682.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,44817.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42682.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42682.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42682.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,47620.59,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47620.59,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42682.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42682.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,65137.15,,facility
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,120,RC,,,,inpatient,,,,,24948.99,,,,,,,case rate,,18319.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18319.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27017.48,,,,,,,case rate,,28496.42,,,,,,,case rate,,23990.49,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18319.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17403.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18319.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18319.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18319.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19235.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18319.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18319.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18319.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19235.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18319.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18319.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18319.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25837.94,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25837.94,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18319.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18319.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28496.42,,facility
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,120,RC,,,,inpatient,,,,,93130.07,,,,,,,case rate,,72944.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,72944.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,72944.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,69296.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72944.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72944.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72944.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,76591.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,72944.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72944.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,72944.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,76591.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,72944.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,72944.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72944.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,72944.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72944.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,93130.07,,facility
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,120,RC,,,,inpatient,,,,,163996.77,,,,,,,case rate,,118326.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,118326.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,176887.21,,,,,,,case rate,,186570.07,,,,,,,case rate,,157069.12,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,118326.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,112410.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,118326.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,118326.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,118326.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,124242.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,118326.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,118326.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,118326.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,124242.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,118326.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,118326.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,118326.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,169164.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,169164.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,118326.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,118326.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,186570.07,,facility
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,120,RC,,,,inpatient,,,,,52999.11,,,,,,,case rate,,39773.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39773.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,58814.05,,,,,,,case rate,,62033.55,,,,,,,case rate,,52224.64,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,39773.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37784.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39773.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39773.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39773.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41761.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39773.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39773.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39773.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41761.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39773.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39773.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39773.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,56246.33,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,56246.33,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39773.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39773.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,62033.55,,facility
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,120,RC,,,,inpatient,,,,,67917.63,,,,,,,case rate,,49775.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49775.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,72727.61,,,,,,,case rate,,76708.74,,,,,,,case rate,,64579.36,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,49775.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47287.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49775.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49775.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49775.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52264.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49775.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49775.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49775.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,52264.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49775.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49775.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49775.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,69552.45,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,69552.45,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49775.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49775.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,76708.74,,facility
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,120,RC,,,,inpatient,,,,,15293.36,,,,,,,case rate,,11342.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11342.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16978.1,,,,,,,case rate,,17907.48,,,,,,,case rate,,15075.91,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11342.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10775.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11342.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11342.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11342.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11909.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11342.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11342.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11342.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11909.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11342.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11342.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11342.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16236.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16236.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11342.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,733.76,733.76,733.76,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,11342.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17907.48,,facility
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,120,RC,,,,inpatient,,,,,30821.56,,,,,,,case rate,,23679.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23679.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32166.09,,,,,,,case rate,,33926.87,,,,,,,case rate,,28562.26,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23679.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22495.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23679.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23679.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23679.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23679.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23679.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23679.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24863.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23679.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23679.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23679.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30761.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30761.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23679.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23679.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,33926.87,,facility
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,120,RC,,,,inpatient,,,,,17141.99,,,,,,,case rate,,12684.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12684.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18592.48,,,,,,,case rate,,19610.24,,,,,,,case rate,,16509.41,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12684.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12049.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12684.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12684.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12684.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13318.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12684.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12684.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12684.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13318.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12684.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12684.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12684.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17780.76,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17780.76,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12684.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12684.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,19610.24,,facility
VIRAL ILLNESS WITH MCC,865,MS-DRG,120,RC,,,,inpatient,,,,,22218.2,,,,,,,case rate,,16717.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16717.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26932.08,,,,,,,case rate,,28406.35,,,,,,,case rate,,23914.66,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16717.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15881.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16717.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16717.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16717.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17553.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16717.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16717.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16717.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17553.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16717.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16717.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16717.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25756.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25756.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16717.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16717.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28406.35,,facility
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,120,RC,,,,inpatient,,,,,27506.67,,,,,,,case rate,,20024.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20024.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29886.58,,,,,,,case rate,,31522.58,,,,,,,case rate,,26538.14,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20024.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19023.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20024.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20024.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20024.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21025.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20024.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20024.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20024.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21025.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20024.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20024.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20024.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28581.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28581.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20024.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20024.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,31522.58,,facility
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,120,RC,,,,inpatient,,,,,15353.57,,,,,,,case rate,,11509.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11509.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16610.22,,,,,,,case rate,,17519.47,,,,,,,case rate,,14749.25,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11509.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10933.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11509.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11509.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11509.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12084.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11509.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11509.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11509.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12084.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11509.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11509.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11509.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15885.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15885.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11509.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11509.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17519.47,,facility
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,120,RC,,,,inpatient,,,,,15808.21,,,,,,,case rate,,11654.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11654.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17827.17,,,,,,,case rate,,18803.03,,,,,,,case rate,,15829.85,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11654.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11071.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11654.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11654.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11654.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12237.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11654.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11654.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11654.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12237.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11654.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11654.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11654.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17048.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17048.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11654.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11654.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18803.03,,facility
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,120,RC,,,,inpatient,,,,,52160.6,,,,,,,case rate,,38100.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,38100.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55933.45,,,,,,,case rate,,58995.27,,,,,,,case rate,,49666.78,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,38100.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36195.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38100.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38100.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38100.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,40005.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,38100.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38100.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,38100.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40005.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,38100.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,38100.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38100.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53491.49,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,53491.49,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38100.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38100.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,58995.27,,facility
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,120,RC,,,,inpatient,,,,,12776.33,,,,,,,case rate,,9873.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9873.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12931.47,,,,,,,case rate,,13639.34,,,,,,,case rate,,11482.65,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9873.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9380.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9873.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9873.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9873.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10367.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9873.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9873.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9873.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10367.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9873.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9873.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9873.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12366.9,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12366.9,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9873.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9873.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13639.34,,facility
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,120,RC,,,,inpatient,,,,,22120.35,,,,,,,case rate,,15647.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15647.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23172.85,,,,,,,case rate,,24441.34,,,,,,,case rate,,20576.61,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15647.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14864.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15647.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15647.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15647.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16429.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15647.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15647.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15647.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16429.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15647.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15647.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15647.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22161.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22161.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15647.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15647.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24441.34,,facility
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,120,RC,,,,inpatient,,,,,15556.8,,,,,,,case rate,,11588.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11588.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17436.3,,,,,,,case rate,,18390.77,,,,,,,case rate,,15482.77,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11588.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11009.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11588.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11588.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11588.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12167.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11588.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11588.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11588.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12167.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11588.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11588.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11588.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16675.06,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16675.06,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11588.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11588.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18390.77,,facility
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,120,RC,,,,inpatient,,,,,8237.55,,,,,,,case rate,,6375.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6375.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9180.46,,,,,,,case rate,,9683,,,,,,,case rate,,8151.9,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,6375.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6056.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6375.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6375.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6375.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6694.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6375.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6375.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6375.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6694.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6375.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6375.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6375.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8779.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8779.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6375.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6375.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,9683,,facility
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,120,RC,,,,inpatient,,,,,10352.64,,,,,,,case rate,,7940.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7940.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11459.97,,,,,,,case rate,,12087.29,,,,,,,case rate,,10176.02,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7940.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7543.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7940.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7940.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7940.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8337.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7940.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7940.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7940.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8337.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7940.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7940.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7940.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10959.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10959.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7940.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7940.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12087.29,,facility
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,120,RC,,,,inpatient,,,,,92705.54,,,,,,,case rate,,71479.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,71479.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,102119.86,,,,,,,case rate,,107709.93,,,,,,,case rate,,90678.55,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,71479.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,67905.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71479.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71479.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71479.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,75053.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,71479.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71479.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,71479.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,75053.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,71479.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,71479.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71479.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,97661.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,97661.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,71479.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71479.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,107709.93,,facility
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,120,RC,,,,inpatient,,,,,12091.37,,,,,,,case rate,,9134.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9134.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13204.09,,,,,,,case rate,,13926.89,,,,,,,case rate,,11724.73,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9134.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8678.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9134.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9134.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9134.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9591.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9134.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9134.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9134.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9591.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9134.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9134.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9134.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12627.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12627.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9134.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9134.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13926.89,,facility
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,120,RC,,,,inpatient,,,,,14159.79,,,,,,,case rate,,10339.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10339.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15412.99,,,,,,,case rate,,16256.7,,,,,,,case rate,,13686.15,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10339.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9822.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10339.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10339.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10339.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10856.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10339.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10339.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10339.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10856.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10339.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10339.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10339.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14740.08,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14740.08,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10339.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10339.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16256.7,,facility
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,120,RC,,,,inpatient,,,,,44954.25,,,,,,,case rate,,31756.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31756.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47897.68,,,,,,,case rate,,50519.61,,,,,,,case rate,,42531.32,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,31756.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30168.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31756.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31756.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31756.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33344.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31756.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31756.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31756.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33344.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31756.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31756.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31756.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45806.55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45806.55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31756.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31756.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,50519.61,,facility
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,120,RC,,,,inpatient,,,,,33319.02,,,,,,,case rate,,24461.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24849,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24461.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35401.42,,,,,,,case rate,,37339.3,,,,,,,case rate,,31435.11,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,24461.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23237.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24461.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24461.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24461.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25684.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24461.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24461.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24461.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25684.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24461.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24461.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24461.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33855.85,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33855.85,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24461.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24461.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,37339.3,,facility
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,120,RC,,,,inpatient,,,,,39801.27,,,,,,,case rate,,32386.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32386.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41589.61,,,,,,,case rate,,43866.23,,,,,,,case rate,,36929.99,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,32386.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30767.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32386.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32386.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32386.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,34005.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32386.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32386.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32386.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34005.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32386.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32386.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32386.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39773.87,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39773.87,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32386.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32386.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,43866.23,,facility
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,120,RC,,,,inpatient,,,,,33901.61,,,,,,,case rate,,25682.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25682.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36078.05,,,,,,,case rate,,38052.97,,,,,,,case rate,,32035.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25682.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24398.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25682.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25682.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25682.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26966.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25682.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25682.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25682.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26966.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25682.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25682.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25682.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34502.94,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34502.94,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25682.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25682.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,38052.97,,facility
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,120,RC,,,,inpatient,,,,,22641.22,,,,,,,case rate,,17297.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17297.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24312.61,,,,,,,case rate,,25643.49,,,,,,,case rate,,21588.67,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17297.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16432.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17297.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17297.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17297.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18162.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17297.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17297.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17297.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18162.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17297.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17297.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17297.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23251.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23251.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17297.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17297.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25643.49,,facility
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,120,RC,,,,inpatient,,,,,17510.81,,,,,,,case rate,,13087.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13087.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21041.15,,,,,,,case rate,,22192.95,,,,,,,case rate,,18683.74,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13087.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12432.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13087.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13087.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13087.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13741.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13087.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13087.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13087.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13741.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13087.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13087.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13087.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20122.53,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20122.53,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13087.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13087.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22192.95,,facility
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,120,RC,,,,inpatient,,,,,10277.37,,,,,,,case rate,,7872.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7872.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11376.21,,,,,,,case rate,,11998.95,,,,,,,case rate,,10101.64,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7872.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7478.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7872.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7872.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7872.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8265.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7872.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7872.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7872.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8265.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7872.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7872.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7872.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10879.55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10879.55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7872.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7872.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,11998.95,,facility
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,120,RC,,,,inpatient,,,,,51063.17,,,,,,,case rate,,35081.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35081.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,56743.11,,,,,,,case rate,,59849.24,,,,,,,case rate,,50385.72,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,35081.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33327.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35081.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35081.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35081.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36835.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35081.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35081.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35081.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36835.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35081.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35081.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35081.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,54265.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,54265.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35081.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35081.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,59849.24,,facility
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,120,RC,,,,inpatient,,,,,23267.46,,,,,,,case rate,,17866.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17866.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24848,,,,,,,case rate,,26208.19,,,,,,,case rate,,22064.08,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17866.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16973.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17866.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17866.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17866.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18759.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17866.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17866.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17866.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18759.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17866.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17866.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17866.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23763.18,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23763.18,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17866.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17866.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26208.19,,facility
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,120,RC,,,,inpatient,,,,,36877.78,,,,,,,case rate,,27022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1843,,,,,,,per diem,,3909,,,,,,,per diem,,36056.47,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,27022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25671.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28374.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28374.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3796,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4352,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36877.78,,facility
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,120,RC,,,,inpatient,,,,,25027.28,,,,,,,case rate,,18475.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18475.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24792.16,,,,,,,case rate,,26149.29,,,,,,,case rate,,22014.5,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18475.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17551.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18475.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18475.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18475.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19399.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18475.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18475.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18475.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19399.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18475.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18475.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18475.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23709.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23709.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18475.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18475.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26149.29,,facility
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,120,RC,,,,inpatient,,,,,14379.58,,,,,,,case rate,,9797.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9797.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14570.49,,,,,,,case rate,,15368.08,,,,,,,case rate,,12938.04,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9797.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9307.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9797.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9797.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9797.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10286.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9797.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9797.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9797.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10286.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9797.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9797.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9797.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13934.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13934.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9797.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9797.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15368.08,,facility
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,120,RC,,,,inpatient,,,,,90185.5,,,,,,,case rate,,66895.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,66895.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,102579.7,,,,,,,case rate,,108194.94,,,,,,,case rate,,91086.88,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,66895.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,63550.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66895.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66895.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66895.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,70240.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,66895.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66895.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,66895.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,70240.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,66895.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,66895.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66895.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,98101.25,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,98101.25,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,66895.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66895.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,108194.94,,facility
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,120,RC,,,,inpatient,,,,,59276.63,,,,,,,case rate,,39218.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39218.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,63839.49,,,,,,,case rate,,67334.08,,,,,,,case rate,,56687.04,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,39218.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37257.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39218.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39218.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39218.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41179.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39218.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39218.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39218.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41179.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39218.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39218.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39218.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,61052.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,61052.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39218.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39218.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,67334.08,,facility
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,120,RC,,,,inpatient,,,,,24812,,,,,,,case rate,,16556.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16556.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26009.11,,,,,,,case rate,,27432.85,,,,,,,case rate,,23095.1,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16556.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15728.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16556.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16556.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16556.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17384.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16556.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16556.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16556.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17384.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16556.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16556.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16556.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24873.59,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24873.59,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16556.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16556.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27432.85,,facility
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,120,RC,,,,inpatient,,,,,13270.1,,,,,,,case rate,,9847.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9847.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14304.43,,,,,,,case rate,,15087.46,,,,,,,case rate,,12701.79,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9847.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9355.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9847.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9847.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9847.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10340.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9847.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9847.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9847.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10340.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9847.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9847.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9847.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13679.93,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13679.93,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9847.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9847.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15087.46,,facility
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,120,RC,,,,inpatient,,,,,10741.03,,,,,,,case rate,,7575.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7575.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11770.36,,,,,,,case rate,,12414.68,,,,,,,case rate,,10451.64,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7575.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7196.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7575.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7575.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7575.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7954.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7575.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7575.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7575.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7954.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7575.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7575.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7575.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11256.49,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11256.49,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7575.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7575.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12414.68,,facility
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,120,RC,,,,inpatient,,,,,22567.45,,,,,,,case rate,,17027.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17027.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24199.29,,,,,,,case rate,,25523.97,,,,,,,case rate,,21488.05,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17027.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16176.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17027.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17027.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17027.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17879.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17027.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17027.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17027.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17879.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17027.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17027.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17027.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23142.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23142.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17027.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17027.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25523.97,,facility
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,120,RC,,,,inpatient,,,,,17512.32,,,,,,,case rate,,13448.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13448.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18411.83,,,,,,,case rate,,19419.69,,,,,,,case rate,,16349,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13448.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12775.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13448.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13448.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13448.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14120.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13448.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13448.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13448.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14120.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13448.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13448.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13448.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17608,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17608,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13448.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13448.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,19419.69,,facility
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,120,RC,,,,inpatient,,,,,9542.73,,,,,,,case rate,,6662.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6662.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9945.77,,,,,,,case rate,,10490.2,,,,,,,case rate,,8831.46,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,6662.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6329.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6662.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6662.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6662.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6996.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6662.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6662.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6662.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6996.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6662.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6662.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6662.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9511.55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9511.55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6662.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6662.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,10490.2,,facility
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,120,RC,,,,inpatient,,,,,100374.05,,,,,,,case rate,,75018.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,75018.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,112574.74,,,,,,,case rate,,118737.11,,,,,,,case rate,,99962.09,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,75018.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,71267.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75018.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75018.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75018.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,78769.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,75018.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75018.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,75018.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,78769.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,75018.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,75018.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75018.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107659.92,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,107659.92,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,75018.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75018.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,118737.11,,facility
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,120,RC,,,,inpatient,,,,,26445.36,,,,,,,case rate,,18547.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18547.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26285.01,,,,,,,case rate,,27723.86,,,,,,,case rate,,23340.09,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18547.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17619.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18547.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18547.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18547.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19474.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18547.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18547.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18547.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19474.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18547.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18547.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18547.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25137.45,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25137.45,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18547.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18547.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27723.86,,facility
AICD LEAD PROCEDURES,265,MS-DRG,120,RC,,,,inpatient,,,,,53700.63,,,,,,,case rate,,39691.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39691.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,58040.52,,,,,,,case rate,,61217.68,,,,,,,case rate,,51537.78,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,39691.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37707.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39691.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39691.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39691.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41676.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39691.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39691.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39691.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41676.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39691.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39691.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39691.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55506.57,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55506.57,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39691.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39691.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,61217.68,,facility
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,120,RC,,,,inpatient,,,,,14575.28,,,,,,,case rate,,10852.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10852.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 3.00 + Fixed Amount 8669.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,7842,,,,,,,case rate,,8095,,,,,,,case rate,,11829.73,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10852.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10309.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10852.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10852.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10852.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11395.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10852.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10852.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10852.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11395.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10852.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10852.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10852.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 2.00 + Fixed Amount 11638.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Outlier Per Diem Second Dollar + Days Threshold 2.00 + Fixed Amount 13781.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,10852.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10852.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16374,,facility
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,120,RC,,,,inpatient,,,,,71565.21,,,,,,,case rate,,51326.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,51326.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,77851.59,,,,,,,case rate,,82113.21,,,,,,,case rate,,69129.25,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,51326.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48760.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51326.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51326.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51326.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,53893.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,51326.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51326.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,51326.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,53893.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,51326.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51326.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51326.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,74452.72,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,74452.72,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,51326.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51326.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,82113.21,,facility
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,120,RC,,,,inpatient,,,,,18153.62,,,,,,,case rate,,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19743.73,,,,,,,case rate,,20824.51,,,,,,,case rate,,17531.68,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12851.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14204.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14204.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18881.75,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18881.75,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13528.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20824.51,,facility
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,120,RC,,,,inpatient,,,,,12053.74,,,,,,,case rate,,9118.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9118.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14611.54,,,,,,,case rate,,15411.38,,,,,,,case rate,,12974.5,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9118.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8662.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9118.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9118.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9118.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9574.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9118.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9118.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9118.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9574.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9118.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9118.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9118.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13973.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13973.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9118.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9118.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15411.38,,facility
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,120,RC,,,,inpatient,,,,,30568,,,,,,,case rate,,17823.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24849,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17823.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26641.39,,,,,,,case rate,,28099.75,,,,,,,case rate,,23656.54,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17823.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16932,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17823.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17823.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17823.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18714.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17823.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17823.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17823.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18714.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17823.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17823.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17823.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25478.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25478.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17823.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17823.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30568,,facility
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,120,RC,,,,inpatient,,,,,116480.33,,,,,,,case rate,,83692.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,83692.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,126641.04,,,,,,,case rate,,133573.41,,,,,,,case rate,,112452.43,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,83692.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,79507.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83692.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83692.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83692.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,87877.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,83692.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83692.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,83692.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,87877.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,83692.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,83692.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83692.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,121112.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,121112.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,83692.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83692.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,133573.41,,facility
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,120,RC,,,,inpatient,,,,,24652.43,,,,,,,case rate,,19310.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19310.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28076.76,,,,,,,case rate,,29613.69,,,,,,,case rate,,24931.1,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19310.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18344.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19310.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19310.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19310.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20275.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19310.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19310.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19310.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20275.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19310.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19310.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19310.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26850.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26850.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19310.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19310.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29613.69,,facility
OSTEOMYELITIS WITH MCC,539,MS-DRG,120,RC,,,,inpatient,,,,,30445.21,,,,,,,case rate,,21826.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21826.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32589.8,,,,,,,case rate,,34373.78,,,,,,,case rate,,28938.51,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21826.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20735.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21826.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21826.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21826.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22917.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21826.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21826.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21826.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22917.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21826.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21826.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21826.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31166.99,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31166.99,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21826.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21826.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,34373.78,,facility
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,120,RC,,,,inpatient,,,,,30532.52,,,,,,,case rate,,23102.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23102.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32064.27,,,,,,,case rate,,33819.47,,,,,,,case rate,,28471.85,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23102.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21946.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23102.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23102.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23102.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24257.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23102.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23102.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23102.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24257.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23102.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23102.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23102.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30664.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30664.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23102.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23102.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,33819.47,,facility
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,120,RC,,,,inpatient,,,,,10893.07,,,,,,,case rate,,8651.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8651.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 3.00 + Fixed Amount 8669.00,13214.8,13214.8,13214.8,1 through 10,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7842,,,,,,,case rate,,8095,,,,,,,case rate,,10889.13,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8651.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8218.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8651.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8651.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8651.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9084.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8651.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8651.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8651.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2122,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1804,,,,,,,per diem,,9084.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8651.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8651.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8651.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 2.00 + Fixed Amount 11638.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Outlier Per Diem Second Dollar + Days Threshold 2.00 + Fixed Amount 13781.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,8651.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8651.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16374,,facility
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,120,RC,,,,inpatient,,,,,12932.89,,,,,,,case rate,,9616.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9616.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13943.13,,,,,,,case rate,,14706.38,,,,,,,case rate,,12380.97,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9616.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9135.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9616.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9616.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9616.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10096.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9616.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9616.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9616.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10096.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9616.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9616.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9616.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13334.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13334.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9616.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9616.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14706.38,,facility
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,120,RC,,,,inpatient,,,,,24929.42,,,,,,,case rate,,17812.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17812.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26598.69,,,,,,,case rate,,28054.71,,,,,,,case rate,,23618.63,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17812.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16921.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17812.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17812.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17812.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18702.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17812.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17812.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17812.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18702.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17812.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17812.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17812.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25437.44,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25437.44,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17812.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17812.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28054.71,,facility
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,120,RC,,,,inpatient,,,,,10920.17,,,,,,,case rate,,8363.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8363.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11767.08,,,,,,,case rate,,12411.21,,,,,,,case rate,,10448.72,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8363.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7945.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8363.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8363.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8363.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8781.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8363.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8363.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8363.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8781.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8363.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8363.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8363.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11253.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11253.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8363.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8363.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12411.21,,facility
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,120,RC,,,,inpatient,,,,,12607.72,,,,,,,case rate,,8649.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8649.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12465.06,,,,,,,case rate,,13147.4,,,,,,,case rate,,11068.5,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8649.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8216.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8649.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8649.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8649.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9081.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8649.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8649.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8649.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9081.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8649.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8649.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8649.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11920.85,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11920.85,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8649.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8649.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13147.4,,facility
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,120,RC,,,,inpatient,,,,,16905.64,,,,,,,case rate,,12484.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12484.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18098.15,,,,,,,case rate,,19088.84,,,,,,,case rate,,16070.47,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12484.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11860.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12484.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12484.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12484.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13108.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12484.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12484.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12484.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13108.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12484.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12484.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12484.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17308.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17308.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12484.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12484.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,19088.84,,facility
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,120,RC,,,,inpatient,,,,,97217.23,,,,,,,case rate,,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,104537.32,,,,,,,case rate,,110259.73,,,,,,,case rate,,92825.17,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,68151.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,75325.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,75325.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,99973.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,99973.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,71738.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,110259.73,,facility
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,120,RC,,,,inpatient,,,,,90864.44,,,,,,,case rate,,59351.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,59351.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,101444.87,,,,,,,case rate,,106997.99,,,,,,,case rate,,90079.19,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,59351.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,56384.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59351.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59351.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59351.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,62319.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,59351.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59351.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,59351.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62319.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,59351.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59351.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59351.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,59351.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59351.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,106997.99,,facility
CHEST PAIN,313,MS-DRG,120,RC,,,,inpatient,,,,,10739.52,,,,,,,case rate,,8283.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8283.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11883.68,,,,,,,case rate,,12534.2,,,,,,,case rate,,10552.26,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8283.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7868.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8283.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8283.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8283.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8697.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8283.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8283.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8283.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8697.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8283.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8283.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8283.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11364.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11364.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8283.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8283.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12534.2,,facility
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,120,RC,,,,inpatient,,,,,36296.7,,,,,,,case rate,,23997.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23997.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,43555.44,,,,,,,case rate,,45939.68,,,,,,,case rate,,38675.57,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23997.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22797.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23997.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23997.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23997.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25197.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23997.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23997.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23997.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25197.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23997.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23997.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23997.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41653.88,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41653.88,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23997.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23997.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,45939.68,,facility
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,120,RC,,,,inpatient,,,,,81306.65,,,,,,,case rate,,62247.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62247.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,93014.95,,,,,,,case rate,,98106.61,,,,,,,case rate,,82593.74,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,62247.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,59135.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62247.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62247.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62247.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,65359.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,62247.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62247.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62247.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,65359.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,62247.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62247.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62247.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,88954.07,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,88954.07,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,62247.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62247.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,98106.61,,facility
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,120,RC,,,,inpatient,,,,,13307.74,,,,,,,case rate,,10393.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10393.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14554.06,,,,,,,case rate,,15350.76,,,,,,,case rate,,12923.45,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10393.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9873.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10393.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10393.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10393.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10912.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10393.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10393.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10393.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10912.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10393.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10393.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10393.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13918.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13918.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10393.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10393.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15350.76,,facility
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,120,RC,,,,inpatient,,,,,138675.94,,,,,,,case rate,,94326.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,94326.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,94326.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,89609.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,94326.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,94326.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,94326.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,99042.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,94326.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,94326.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,94326.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,99042.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,94326.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,94326.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,94326.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,94326.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,94326.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,138675.94,,facility
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,120,RC,,,,inpatient,,,,,159494.12,,,,,,,case rate,,108387.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,108387.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,167757.66,,,,,,,case rate,,176940.77,,,,,,,case rate,,148962.43,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,108387.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,102968.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108387.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108387.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108387.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,113806.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,108387.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108387.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,108387.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,113806.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,108387.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108387.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108387.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,160433.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,160433.65,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,108387.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108387.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,176940.77,,facility
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,120,RC,,,,inpatient,,,,,27467.53,,,,,,,case rate,,20385.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20385.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28902.84,,,,,,,case rate,,30484.99,,,,,,,case rate,,25664.62,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20385.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19365.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20385.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20385.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20385.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21404.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20385.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20385.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20385.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21404.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20385.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20385.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20385.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27640.99,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27640.99,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20385.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20385.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30484.99,,facility
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,120,RC,,,,inpatient,,,,,13455.27,,,,,,,case rate,,10184.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10184.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14708.44,,,,,,,case rate,,15513.58,,,,,,,case rate,,13060.53,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10184.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9675.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10184.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10184.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10184.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10694.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10184.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10184.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10184.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10694.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10184.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10184.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10184.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14066.29,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14066.29,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10184.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10184.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15513.58,,facility
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,120,RC,,,,inpatient,,,,,31655.55,,,,,,,case rate,,23563.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23563.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35697.03,,,,,,,case rate,,37651.1,,,,,,,case rate,,31697.61,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23563.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22385.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23563.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23563.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23563.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24741.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23563.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23563.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23563.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24741.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23563.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23563.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23563.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34138.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34138.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23563.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23563.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,37651.1,,facility
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,120,RC,,,,inpatient,,,,,14376.57,,,,,,,case rate,,10889.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10889.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16253.84,,,,,,,case rate,,17143.58,,,,,,,case rate,,14432.8,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10889.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10344.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10889.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10889.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10889.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11433.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10889.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10889.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10889.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11433.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10889.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10889.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10889.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15544.23,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15544.23,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10889.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10889.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17143.58,,facility
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,120,RC,,,,inpatient,,,,,32280.29,,,,,,,case rate,,23164.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23164.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34361.84,,,,,,,case rate,,36242.82,,,,,,,case rate,,30512.01,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23164.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22006.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23164.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23164.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23164.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24323.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23164.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23164.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23164.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24323.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23164.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23164.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23164.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32861.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32861.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23164.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23164.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36242.82,,facility
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,120,RC,,,,inpatient,,,,,102793.23,,,,,,,case rate,,73427.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,73427.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,100019.35,,,,,,,case rate,,105494.44,,,,,,,case rate,,88813.39,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,73427.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,69756.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73427.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73427.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73427.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,77098.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73427.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73427.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,73427.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,77098.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73427.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73427.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73427.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,95652.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,95652.68,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73427.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73427.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,105494.44,,facility
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,120,RC,,,,inpatient,,,,,27679.79,,,,,,,case rate,,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30251.17,,,,,,,case rate,,31907.12,,,,,,,case rate,,26861.89,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19232.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21256.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21256.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28930.45,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28930.45,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,31907.12,,facility
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,120,RC,,,,inpatient,,,,,81229.88,,,,,,,case rate,,59588.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,59588.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,84681.91,,,,,,,case rate,,89317.43,,,,,,,case rate,,75194.32,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,59588.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,56608.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59588.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59588.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59588.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,62567.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,59588.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59588.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,59588.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,62567.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,59588.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59588.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59588.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,280816,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,80984.85,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,59588.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,59588.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,280816,,facility
DIABETES WITH CC,638,MS-DRG,120,RC,,,,inpatient,,,,,13807.53,,,,,,,case rate,,10192.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10192.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14770.85,,,,,,,case rate,,15579.41,,,,,,,case rate,,13115.95,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10192.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9682.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10192.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10192.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10192.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10702.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10192.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10192.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10192.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10702.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10192.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10192.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10192.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14125.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14125.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10192.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10192.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15579.41,,facility
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,120,RC,,,,inpatient,,,,,13893.34,,,,,,,case rate,,10431.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10431.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14792.2,,,,,,,case rate,,15601.93,,,,,,,case rate,,13134.91,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10431.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9909.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10431.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10431.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10431.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10952.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10431.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10431.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10431.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10952.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10431.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10431.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10431.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14146.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14146.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10431.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10431.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15601.93,,facility
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,120,RC,,,,inpatient,,,,,16917.69,,,,,,,case rate,,12885.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12885.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18280.44,,,,,,,case rate,,19281.12,,,,,,,case rate,,16232.34,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12885.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12241.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12885.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12885.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12885.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13529.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12885.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12885.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12885.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13529.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12885.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12885.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12885.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17482.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17482.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12885.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12885.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,19281.12,,facility
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,120,RC,,,,inpatient,,,,,59970.62,,,,,,,case rate,,42087.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42087.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,61085.35,,,,,,,case rate,,64429.18,,,,,,,case rate,,54241.47,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,42087.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,39983.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42087.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42087.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42087.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44192.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42087.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42087.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42087.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,44192.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42087.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42087.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42087.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58418.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,58418.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42087.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42087.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,64429.18,,facility
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,120,RC,,,,inpatient,,,,,25432.23,,,,,,,case rate,,19439.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19439.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28656.49,,,,,,,case rate,,30225.16,,,,,,,case rate,,25445.88,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19439.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18467.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19439.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19439.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19439.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20410.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19439.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19439.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19439.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20410.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19439.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19439.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19439.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27405.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27405.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19439.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19439.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30225.16,,facility
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,120,RC,,,,inpatient,,,,,15865.41,,,,,,,case rate,,11599.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11599.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17437.94,,,,,,,case rate,,18392.5,,,,,,,case rate,,15484.23,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11599.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11019.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11599.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11599.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11599.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12179.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11599.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11599.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11599.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12179.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11599.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11599.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11599.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16676.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16676.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11599.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11599.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18392.5,,facility
KIDNEY TRANSPLANT,652,MS-DRG,120,RC,,,,inpatient,,,,,46236.86,,,,,,,case rate,,35479.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35479.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49341.26,,,,,,,case rate,,52042.22,,,,,,,case rate,,43813.17,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,35479.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33705.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35479.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35479.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35479.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37253.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35479.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35479.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35479.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37253.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35479.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35479.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35479.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,47187.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47187.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35479.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35479.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,52042.22,,facility
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,120,RC,,,,inpatient,,,,,33994.94,,,,,,,case rate,,24308.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24308.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36634.79,,,,,,,case rate,,38640.19,,,,,,,case rate,,32530.3,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,24308.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23092.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24308.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24308.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24308.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25523.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24308.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24308.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24308.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25523.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24308.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24308.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24308.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35035.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35035.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24308.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24308.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,38640.19,,facility
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,120,RC,,,,inpatient,,,,,10361.67,,,,,,,case rate,,7897.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7897.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11290.81,,,,,,,case rate,,11908.88,,,,,,,case rate,,10025.81,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7897.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7502.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7897.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7897.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7897.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7897.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7897.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7897.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7897.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7897.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7897.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10797.88,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10797.88,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7897.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7897.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,11908.88,,facility
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,120,RC,,,,inpatient,,,,,15427.34,,,,,,,case rate,,12807.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12807.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17012.59,,,,,,,case rate,,17943.86,,,,,,,case rate,,15106.53,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12807.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12167.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12807.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12807.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12807.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13448.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12807.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12807.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12807.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13448.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12807.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12807.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12807.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16269.85,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16269.85,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12807.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12807.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17943.86,,facility
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,120,RC,,,,inpatient,,,,,6649.35,,,,,,,case rate,,5412.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,5412.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7208.05,,,,,,,case rate,,7602.63,,,,,,,case rate,,6400.48,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,5412.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5141.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5412.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5412.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5412.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5682.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5412.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5412.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,5412.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,5682.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5412.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5412.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5412.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6893.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6893.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5412.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5412.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,7602.63,,facility
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,120,RC,,,,inpatient,,,,,54546.66,,,,,,,case rate,,39179.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39179.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,58712.22,,,,,,,case rate,,61926.15,,,,,,,case rate,,52134.23,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,39179.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37220.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39179.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39179.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39179.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41138.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39179.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39179.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39179.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41138.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39179.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39179.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39179.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,56148.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,56148.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39179.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39179.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,61926.15,,facility
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,120,RC,,,,inpatient,,,,,23881.67,,,,,,,case rate,,18155.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18155.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26086.29,,,,,,,case rate,,27514.26,,,,,,,case rate,,23163.64,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18155.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17248.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18155.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18155.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18155.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19063.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18155.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18155.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18155.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19063.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18155.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18155.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18155.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24947.41,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24947.41,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18155.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18155.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27514.26,,facility
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,120,RC,,,,inpatient,,,,,15520.67,,,,,,,case rate,,11570.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11570.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16914.05,,,,,,,case rate,,17839.93,,,,,,,case rate,,15019.03,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11570.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10991.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11570.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11570.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11570.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12148.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11570.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11570.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11570.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12148.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11570.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11570.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11570.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16175.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16175.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11570.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11570.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17839.93,,facility
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,120,RC,,,,inpatient,,,,,16395.31,,,,,,,case rate,,12222.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12222.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17621.88,,,,,,,case rate,,18586.51,,,,,,,case rate,,15647.56,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12222.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11611.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12222.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12222.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12222.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12833.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12222.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12222.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12222.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12833.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12222.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12222.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12222.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16852.54,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16852.54,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12222.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12222.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18586.51,,facility
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,120,RC,,,,inpatient,,,,,28566.47,,,,,,,case rate,,21228.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21228.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30952.43,,,,,,,case rate,,32646.77,,,,,,,case rate,,27484.58,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21228.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20166.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21228.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21228.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21228.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22289.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21228.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21228.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21228.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22289.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21228.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21228.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21228.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29601.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29601.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21228.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21228.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32646.77,,facility
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,120,RC,,,,inpatient,,,,,357123.03,,,,,,,case rate,,231862.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,231862.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,432888.93,,,,,,,case rate,,456585.4,,,,,,,case rate,,384388.92,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,231862.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,220269.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,231862.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,231862.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,231862.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,243455.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,231862.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,231862.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,231862.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,243455.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,231862.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,231862.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,231862.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,413989.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,413989.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,231862.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,231862.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,456585.4,,facility
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,120,RC,,,,inpatient,,,,,16711.45,,,,,,,case rate,,12269,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12269,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17814.03,,,,,,,case rate,,18789.17,,,,,,,case rate,,15818.18,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12269,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11655.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12269,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12269,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12269,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12882.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12269,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12269,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12269,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12882.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12269,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12269,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12269,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17036.3,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17036.3,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12269,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12269,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18789.17,,facility
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,120,RC,,,,inpatient,,,,,14400.66,,,,,,,case rate,,11768.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11768.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16841.79,,,,,,,case rate,,17763.71,,,,,,,case rate,,14954.87,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11768.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11179.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11768.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11768.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11768.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12356.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11768.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11768.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11768.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12356.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11768.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11768.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11768.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16106.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16106.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11768.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11768.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17763.71,,facility
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,120,RC,,,,inpatient,,,,,35583.14,,,,,,,case rate,,26459.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26459.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38957,,,,,,,case rate,,41089.52,,,,,,,case rate,,34592.33,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,26459.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25136.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26459.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26459.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26459.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27782.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26459.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26459.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26459.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27782.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26459.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26459.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26459.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37256.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37256.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26459.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26459.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,41089.52,,facility
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,120,RC,,,,inpatient,,,,,34535.38,,,,,,,case rate,,23427.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23427.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34668.95,,,,,,,case rate,,36566.74,,,,,,,case rate,,30784.71,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23427.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22255.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23427.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23427.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23427.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24598.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23427.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23427.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23427.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24598.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23427.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23427.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23427.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33155.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33155.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23427.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23427.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36566.74,,facility
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,120,RC,,,,inpatient,,,,,197234.5,,,,,,,case rate,,130722.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,130722.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,188222.36,,,,,,,case rate,,198525.71,,,,,,,case rate,,167134.3,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,130722.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,124186.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,130722.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,130722.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,130722.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,137258.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,130722.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,130722.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,130722.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,137258.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,130722.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,130722.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,130722.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,180004.9,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,180004.9,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,130722.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,130722.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,198525.71,,facility
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,120,RC,,,,inpatient,,,,,28387.33,,,,,,,case rate,,20027.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20027.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30208.47,,,,,,,case rate,,31862.09,,,,,,,case rate,,26823.97,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20027.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19026.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20027.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20027.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20027.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21028.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20027.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20027.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20027.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21028.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20027.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20027.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20027.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28889.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28889.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20027.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20027.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,31862.09,,facility
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,120,RC,,,,inpatient,,,,,29778.32,,,,,,,case rate,,22877.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22877.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32448.56,,,,,,,case rate,,34224.81,,,,,,,case rate,,28813.09,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22877.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21733.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22877.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22877.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22877.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24021.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22877.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22877.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22877.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24021.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22877.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22877.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22877.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31031.91,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31031.91,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22877.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22877.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,34224.81,,facility
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,120,RC,,,,inpatient,,,,,29436.59,,,,,,,case rate,,21946.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21946.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32376.3,,,,,,,case rate,,34148.59,,,,,,,case rate,,28748.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21946.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20849.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21946.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21946.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21946.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23044.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21946.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21946.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21946.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23044.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21946.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21946.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21946.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30962.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30962.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21946.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21946.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,34148.59,,facility
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,120,RC,,,,inpatient,,,,,69126.46,,,,,,,case rate,,50293.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,50293.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,74179.41,,,,,,,case rate,,78240.01,,,,,,,case rate,,65868.49,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,50293.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47779.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50293.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50293.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50293.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52808.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50293.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50293.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,50293.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,52808.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,50293.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50293.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50293.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,70940.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,70940.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50293.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,50293.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,78240.01,,facility
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,120,RC,,,,inpatient,,,,,15692.29,,,,,,,case rate,,11651.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11651.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16853.28,,,,,,,case rate,,17775.84,,,,,,,case rate,,14965.07,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11651.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11068.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11651.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11651.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11651.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12233.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11651.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11651.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11651.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12233.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11651.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11651.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11651.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16117.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16117.5,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11651.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11651.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17775.84,,facility
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,120,RC,,,,inpatient,,,,,13803.01,,,,,,,case rate,,9423.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9423.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15150.22,,,,,,,case rate,,15979.55,,,,,,,case rate,,13452.82,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9423.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8951.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9423.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9423.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9423.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9894.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9423.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9423.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9423.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9894.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9423.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9423.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9423.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14488.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14488.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9423.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9423.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15979.55,,facility
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,120,RC,,,,inpatient,,,,,11129.42,,,,,,,case rate,,8453.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8453.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12230.21,,,,,,,case rate,,12899.69,,,,,,,case rate,,10859.96,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8453.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8030.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8453.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8453.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8453.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8875.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8453.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8453.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8453.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8875.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8453.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8453.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8453.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11696.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11696.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8453.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8453.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12899.69,,facility
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,120,RC,,,,inpatient,,,,,28968.41,,,,,,,case rate,,21745.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21745.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32000.22,,,,,,,case rate,,33751.92,,,,,,,case rate,,28414.98,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21745.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20657.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21745.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21745.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21745.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22832.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21745.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21745.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21745.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22832.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21745.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21745.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21745.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30603.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30603.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21745.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21745.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,33751.92,,facility
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,120,RC,,,,inpatient,,,,,13635.91,,,,,,,case rate,,10679.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10679.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15002.41,,,,,,,case rate,,15823.65,,,,,,,case rate,,13321.57,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10679.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10145.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10679.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10679.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10679.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10679.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10679.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10679.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11213.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10679.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10679.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10679.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14347.43,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14347.43,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10679.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10679.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15823.65,,facility
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,120,RC,,,,inpatient,,,,,17474.68,,,,,,,case rate,,22315.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22315.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21182.39,,,,,,,case rate,,22341.92,,,,,,,case rate,,18809.15,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22315.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21199.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22315.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22315.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22315.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23430.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22315.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22315.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22315.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23430.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22315.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22315.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22315.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20257.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20257.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22315.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22315.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23430.97,,facility
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,120,RC,,,,inpatient,,,,,23329.18,,,,,,,case rate,,16594.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16594.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25567.33,,,,,,,case rate,,26966.89,,,,,,,case rate,,22702.81,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16594.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15764.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16594.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16594.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16594.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17423.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16594.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16594.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16594.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17423.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16594.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16594.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16594.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24451.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24451.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16594.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16594.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26966.89,,facility
CELLULITIS WITHOUT MCC,603,MS-DRG,120,RC,,,,inpatient,,,,,13259.56,,,,,,,case rate,,9918.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9918.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14529.43,,,,,,,case rate,,15324.77,,,,,,,case rate,,12901.58,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9918.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9422.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9918.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9918.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9918.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10414.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9918.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9918.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9918.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10414.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9918.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9918.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9918.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13895.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13895.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9918.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9918.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15324.77,,facility
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,120,RC,,,,inpatient,,,,,10902.11,,,,,,,case rate,,9044.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9044.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12824.72,,,,,,,case rate,,13526.75,,,,,,,case rate,,11387.86,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9044.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8592.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9044.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9044.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9044.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9497.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9044.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9044.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9044.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9497.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9044.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9044.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9044.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12264.82,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12264.82,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9044.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9044.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13526.75,,facility
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,120,RC,,,,inpatient,,,,,165890.56,,,,,,,case rate,,123286.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,123286.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,201084.85,,,,,,,case rate,,212092.3,,,,,,,case rate,,178555.71,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,123286.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,117122.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,123286.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,123286.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,123286.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,129451.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,123286.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,123286.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,123286.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,129451.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,123286.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123286.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,123286.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,123286.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,123286.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,212092.3,,facility
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,120,RC,,,,inpatient,,,,,37300.8,,,,,,,case rate,,26434.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26434.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36895.91,,,,,,,case rate,,38915.61,,,,,,,case rate,,32762.17,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,26434.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25112.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26434.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26434.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26434.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27756.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26434.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26434.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26434.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27756.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26434.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26434.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26434.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35285.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35285.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26434.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26434.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,38915.61,,facility
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,120,RC,,,,inpatient,,,,,29537.45,,,,,,,case rate,,21531.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21531.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32560.24,,,,,,,case rate,,34342.6,,,,,,,case rate,,28912.26,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21531.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20455.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21531.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21531.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21531.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22608.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21531.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21531.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21531.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22608.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21531.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21531.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21531.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31138.72,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31138.72,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21531.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21531.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,34342.6,,facility
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,120,RC,,,,inpatient,,,,,29587.13,,,,,,,case rate,,19650.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19650.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34596.69,,,,,,,case rate,,36490.53,,,,,,,case rate,,30720.55,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19650.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18667.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19650.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19650.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19650.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20632.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19650.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19650.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19650.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20632.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19650.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19650.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19650.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33086.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33086.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19650.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19650.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36490.53,,facility
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,120,RC,,,,inpatient,,,,,31785.02,,,,,,,case rate,,25805.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25805.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35582.07,,,,,,,case rate,,37529.85,,,,,,,case rate,,31595.53,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25805.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24515.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25805.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25805.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25805.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27096.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25805.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25805.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25805.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27096.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25805.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25805.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25805.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34028.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34028.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25805.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25805.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,37529.85,,facility
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,120,RC,,,,inpatient,,,,,11279.96,,,,,,,case rate,,9156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12433.85,,,,,,,case rate,,13114.49,,,,,,,case rate,,11040.79,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8698.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9614.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9614.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11891.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11891.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13114.49,,facility
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,120,RC,,,,inpatient,,,,,42483.89,,,,,,,case rate,,30817.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30817.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44957.96,,,,,,,case rate,,47418.98,,,,,,,case rate,,39920.96,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,30817.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29276.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30817.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30817.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30817.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32357.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30817.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30817.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30817.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32357.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30817.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30817.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30817.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42995.18,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42995.18,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30817.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30817.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,47418.98,,facility
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,120,RC,,,,inpatient,,,,,12308.15,,,,,,,case rate,,9192.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9192.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12813.22,,,,,,,case rate,,13514.62,,,,,,,case rate,,11377.66,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9192.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8732.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9192.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9192.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9192.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9651.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9192.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9192.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9192.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9651.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9192.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9192.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9192.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12253.82,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12253.82,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9192.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9192.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13514.62,,facility
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,120,RC,,,,inpatient,,,,,27044.51,,,,,,,case rate,,22970.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22970.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27618.56,,,,,,,case rate,,29130.41,,,,,,,case rate,,24524.23,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22970.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21822.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22970.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22970.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22970.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24119.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22970.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22970.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22970.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24119.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22970.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22970.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22970.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26412.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26412.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22970.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22970.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29130.41,,facility
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,120,RC,,,,inpatient,,,,,21575.39,,,,,,,case rate,,16670.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16670.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23509.52,,,,,,,case rate,,24796.44,,,,,,,case rate,,20875.56,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16670.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15836.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16670.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16670.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16670.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17503.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16670.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16670.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16670.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17503.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16670.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16670.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16670.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22483.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22483.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16670.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16670.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24796.44,,facility
HYPERTENSION WITHOUT MCC,305,MS-DRG,120,RC,,,,inpatient,,,,,11301.04,,,,,,,case rate,,8663.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8663.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12374.73,,,,,,,case rate,,13052.13,,,,,,,case rate,,10988.29,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8663.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8230.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8663.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8663.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8663.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9096.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8663.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8663.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8663.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9096.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8663.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8663.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8663.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11834.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11834.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8663.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8663.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13052.13,,facility
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,120,RC,,,,inpatient,,,,,28384.32,,,,,,,case rate,,21384.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21384.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30903.16,,,,,,,case rate,,32594.81,,,,,,,case rate,,27440.83,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21384.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20315.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21384.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21384.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21384.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22453.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21384.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21384.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21384.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22453.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21384.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21384.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21384.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29553.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29553.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21384.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21384.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32594.81,,facility
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,120,RC,,,,inpatient,,,,,127495.34,,,,,,,case rate,,91550.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,91550.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,138436.04,,,,,,,case rate,,146014.07,,,,,,,case rate,,122925.94,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,91550.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,86973.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,91550.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,91550.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,91550.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,96128.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,91550.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,91550.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,91550.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,96128.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,91550.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,91550.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,91550.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,132392.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,132392.16,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,91550.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,91550.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,146014.07,,facility
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,120,RC,,,,inpatient,,,,,23604.67,,,,,,,case rate,,18160.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18160.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25841.59,,,,,,,case rate,,27256.17,,,,,,,case rate,,22946.35,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18160.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17252.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18160.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18160.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18160.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19068.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18160.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18160.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18160.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19068.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18160.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18160.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18160.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24713.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24713.39,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18160.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18160.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27256.17,,facility
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,120,RC,,,,inpatient,,,,,27235.7,,,,,,,case rate,,19586.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19586.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29945.7,,,,,,,case rate,,31584.93,,,,,,,case rate,,26590.64,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19586.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18607.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19586.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19586.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19586.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20565.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19586.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19586.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19586.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20565.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19586.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19586.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19586.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28638.32,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28638.32,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19586.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19586.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,31584.93,,facility
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,120,RC,,,,inpatient,,,,,22567.45,,,,,,,case rate,,15101.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15101.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24020.28,,,,,,,case rate,,25335.16,,,,,,,case rate,,21329.1,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15101.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14346.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15101.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15101.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15101.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15857,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15101.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15101.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15101.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15857,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15101.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15101.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15101.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22971.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22971.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15101.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15101.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25335.16,,facility
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,120,RC,,,,inpatient,,,,,36144.65,,,,,,,case rate,,27964.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27964.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39443.12,,,,,,,case rate,,41602.25,,,,,,,case rate,,35023.99,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,27964.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26566.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27964.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27964.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27964.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29362.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27964.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27964.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27964.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29362.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27964.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27964.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27964.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37721.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37721.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27964.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27964.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,41602.25,,facility
RECTAL RESECTION WITH CC,333,MS-DRG,120,RC,,,,inpatient,,,,,31994.27,,,,,,,case rate,,25863.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25863.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34151.63,,,,,,,case rate,,36021.1,,,,,,,case rate,,30325.35,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25863.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24570.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25863.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25863.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25863.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25863.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25863.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25863.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27156.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25863.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25863.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25863.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32660.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32660.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25863.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25863.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36021.1,,facility
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,120,RC,,,,inpatient,,,,,50531.76,,,,,,,case rate,,37452.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37452.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,56301.33,,,,,,,case rate,,59383.28,,,,,,,case rate,,49993.44,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,37452.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,35580.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37452.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37452.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37452.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,39325.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,37452.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37452.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37452.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39325.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,37452.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37452.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37452.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53843.31,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,53843.31,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37452.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,37452.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,59383.28,,facility
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,120,RC,,,,inpatient,,,,,29415.52,,,,,,,case rate,,22686.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22686.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30914.66,,,,,,,case rate,,32606.93,,,,,,,case rate,,27451.04,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22686.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21552.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22686.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22686.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22686.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23821.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22686.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22686.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22686.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23821.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22686.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22686.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22686.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29564.97,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29564.97,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22686.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22686.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32606.93,,facility
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,120,RC,,,,inpatient,,,,,71890.38,,,,,,,case rate,,51175.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,51175.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,72077.26,,,,,,,case rate,,76022.79,,,,,,,case rate,,64001.87,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,51175.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48616.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51175.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51175.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51175.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,53733.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,51175.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51175.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,51175.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,53733.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,51175.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51175.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51175.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,68930.49,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,68930.49,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,51175.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51175.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,76022.79,,facility
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,120,RC,,,,inpatient,,,,,11960.4,,,,,,,case rate,,9155.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9155.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13154.82,,,,,,,case rate,,13874.92,,,,,,,case rate,,11680.98,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9155.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8697.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9155.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9155.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9155.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9613.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9155.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9155.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9155.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9613.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9155.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9155.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9155.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12580.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12580.51,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9155.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9155.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13874.92,,facility
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,120,RC,,,,inpatient,,,,,20271.72,,,,,,,case rate,,14804.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14804.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22975.78,,,,,,,case rate,,24233.48,,,,,,,case rate,,20401.62,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14804.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14064.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14804.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14804.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14804.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15545.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14804.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14804.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14804.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15545.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14804.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14804.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14804.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21972.69,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21972.69,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14804.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14804.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24233.48,,facility
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,120,RC,,,,inpatient,,,,,19071.91,,,,,,,case rate,,14875.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14875.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20298.83,,,,,,,case rate,,21409.99,,,,,,,case rate,,18024.59,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14875.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14131.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14875.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14875.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14875.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15619.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14875.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14875.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14875.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15619.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14875.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14875.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14875.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19412.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19412.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14875.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14875.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,21409.99,,facility
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,120,RC,,,,inpatient,,,,,38432.86,,,,,,,case rate,,28609.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28609.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41896.72,,,,,,,case rate,,44190.15,,,,,,,case rate,,37202.69,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,28609.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27179.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28609.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28609.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28609.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30040.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28609.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28609.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28609.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30040.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28609.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28609.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28609.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40067.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40067.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28609.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28609.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,44190.15,,facility
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,120,RC,,,,inpatient,,,,,12597.19,,,,,,,case rate,,9709.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9709.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14204.25,,,,,,,case rate,,14981.8,,,,,,,case rate,,12612.84,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9709.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9223.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9709.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9709.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9709.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10194.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9709.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9709.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9709.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10194.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9709.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9709.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9709.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13584.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13584.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9709.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9709.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14981.8,,facility
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,120,RC,,,,inpatient,,,,,14486.46,,,,,,,case rate,,10919.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10919.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15885.97,,,,,,,case rate,,16755.57,,,,,,,case rate,,14106.14,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10919.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10373.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10919.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10919.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10919.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11465.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10919.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10919.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10919.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11465.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10919.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10919.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10919.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15192.41,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15192.41,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10919.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10919.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16755.57,,facility
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,120,RC,,,,inpatient,,,,,10193.06,,,,,,,case rate,,8229.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8229.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11596.28,,,,,,,case rate,,12231.06,,,,,,,case rate,,10297.06,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8229.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7818.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8229.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8229.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8229.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8641.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8229.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8229.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8229.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8641.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8229.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8229.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8229.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11090.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11090.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8229.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8229.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12231.06,,facility
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,120,RC,,,,inpatient,,,,,31928.03,,,,,,,case rate,,23142.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23142.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32982.31,,,,,,,case rate,,34787.77,,,,,,,case rate,,29287.04,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23142.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21985.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23142.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23142.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23142.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24299.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23142.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23142.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23142.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24299.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23142.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23142.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23142.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31542.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31542.36,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23142.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23142.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,34787.77,,facility
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,120,RC,,,,inpatient,,,,,24968.56,,,,,,,case rate,,18230.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18230.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26360.56,,,,,,,case rate,,27803.54,,,,,,,case rate,,23407.17,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18230.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17319.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18230.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18230.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18230.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19142.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18230.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18230.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18230.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19142.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18230.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18230.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18230.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25209.7,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25209.7,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18230.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18230.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27803.54,,facility
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,120,RC,,,,inpatient,,,,,27441.94,,,,,,,case rate,,19512.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19512.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29384.03,,,,,,,case rate,,30992.52,,,,,,,case rate,,26091.9,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19512.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18537.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19512.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19512.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19512.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20488.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19512.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19512.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19512.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20488.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19512.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19512.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19512.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28101.18,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28101.18,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19512.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19512.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30992.52,,facility
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,120,RC,,,,inpatient,,,,,15835.3,,,,,,,case rate,,11430.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11430.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17513.49,,,,,,,case rate,,18472.18,,,,,,,case rate,,15551.31,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11430.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10858.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11430.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11430.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11430.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12001.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11430.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11430.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11430.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12001.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11430.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11430.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11430.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16748.88,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16748.88,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11430.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11430.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18472.18,,facility
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,120,RC,,,,inpatient,,,,,13170.74,,,,,,,case rate,,9013.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9013.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14089.29,,,,,,,case rate,,14860.54,,,,,,,case rate,,12510.76,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9013.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8562.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9013.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9013.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9013.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9464.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9013.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9013.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9013.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9464.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9013.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9013.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9013.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13474.18,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13474.18,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9013.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9013.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14860.54,,facility
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,120,RC,,,,inpatient,,,,,13261.07,,,,,,,case rate,,9915.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9915.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16025.56,,,,,,,case rate,,16902.81,,,,,,,case rate,,14230.09,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9915.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9419.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9915.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9915.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9915.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10410.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9915.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9915.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9915.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10410.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9915.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9915.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9915.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15325.91,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15325.91,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9915.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9915.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16902.81,,facility
DIABETES WITH MCC,637,MS-DRG,120,RC,,,,inpatient,,,,,21923.14,,,,,,,case rate,,16050.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16050.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23801.85,,,,,,,case rate,,25104.77,,,,,,,case rate,,21135.14,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16050.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15247.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16050.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16050.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16050.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16852.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16050.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16050.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16050.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16852.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16050.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16050.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16050.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22762.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22762.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16050.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16050.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25104.77,,facility
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,120,RC,,,,inpatient,,,,,34750.65,,,,,,,case rate,,25824.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25824.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39122.87,,,,,,,case rate,,41264.47,,,,,,,case rate,,34739.62,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25824.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24533.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25824.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25824.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25824.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27115.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25824.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25824.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25824.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27115.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25824.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25824.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25824.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37414.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37414.83,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25824.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25824.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,41264.47,,facility
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,120,RC,,,,inpatient,,,,,19835.15,,,,,,,case rate,,15281.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15281.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21566.68,,,,,,,case rate,,22747.25,,,,,,,case rate,,19150.4,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15281.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14517.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15281.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15281.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15281.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16045.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15281.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15281.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15281.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16045.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15281.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15281.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15281.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20625.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20625.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15281.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15281.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22747.25,,facility
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,120,RC,,,,inpatient,,,,,77272.18,,,,,,,case rate,,57661.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,57661.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,83049.47,,,,,,,case rate,,87595.62,,,,,,,case rate,,73744.77,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,57661.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,54778.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57661.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57661.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57661.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,60544.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,57661.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57661.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,57661.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,60544.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,57661.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57661.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57661.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,79423.67,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,79423.67,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,57661.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57661.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,87595.62,,facility
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,120,RC,,,,inpatient,,,,,32343.52,,,,,,,case rate,,24117.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24117.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34023.53,,,,,,,case rate,,35885.99,,,,,,,case rate,,30211.6,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,24117.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22911.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24117.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24117.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24117.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25323.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24117.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24117.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24117.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25323.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24117.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24117.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24117.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32538.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32538.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24117.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24117.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,35885.99,,facility
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,120,RC,,,,inpatient,,,,,58183.71,,,,,,,case rate,,38274.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,38274.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,64997.31,,,,,,,case rate,,68555.28,,,,,,,case rate,,57715.14,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,38274.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36360.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38274.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38274.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38274.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,40188,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,38274.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38274.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,38274.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40188,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,38274.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,38274.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38274.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62159.64,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,62159.64,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38274.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38274.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,68555.28,,facility
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,120,RC,,,,inpatient,,,,,46456.64,,,,,,,case rate,,35489.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35489.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,35489.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33714.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35489.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35489.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35489.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37263.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35489.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35489.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35489.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37263.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35489.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35489.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35489.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35489.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35489.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,46456.64,,facility
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,120,RC,,,,inpatient,,,,,24203.82,,,,,,,case rate,,18420.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18420.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26503.44,,,,,,,case rate,,27954.24,,,,,,,case rate,,23534.05,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18420.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17499.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18420.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18420.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18420.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19341.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18420.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18420.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18420.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19341.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18420.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18420.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18420.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25346.34,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25346.34,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18420.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18420.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27954.24,,facility
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,120,RC,,,,inpatient,,,,,12344.28,,,,,,,case rate,,9213.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9213.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13502.99,,,,,,,case rate,,14242.15,,,,,,,case rate,,11990.14,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9213.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8753.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9213.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9213.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9213.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9674.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9213.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9213.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9213.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9674.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9213.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9213.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9213.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12913.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12913.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9213.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9213.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14242.15,,facility
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,120,RC,,,,inpatient,,,,,17327.15,,,,,,,case rate,,13512.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13512.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16583.95,,,,,,,case rate,,17491.76,,,,,,,case rate,,14725.91,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13512.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12836.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13512.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13512.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13512.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14187.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13512.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13512.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13512.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14187.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13512.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13512.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13512.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15859.92,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15859.92,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13512.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13512.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17491.76,,facility
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,120,RC,,,,inpatient,,,,,21572.38,,,,,,,case rate,,15644.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15644.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24159.88,,,,,,,case rate,,25482.39,,,,,,,case rate,,21453.05,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15644.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14862.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15644.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15644.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15644.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16427.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15644.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15644.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15644.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16427.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15644.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15644.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15644.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23105.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23105.1,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15644.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15644.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25482.39,,facility
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,120,RC,,,,inpatient,,,,,48463.34,,,,,,,case rate,,35453.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35453.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,54097.36,,,,,,,case rate,,57058.67,,,,,,,case rate,,48036.4,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,35453.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33680.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35453.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35453.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35453.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37226.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35453.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35453.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35453.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37226.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35453.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35453.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35453.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51735.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,51735.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35453.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35453.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,57058.67,,facility
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,120,RC,,,,inpatient,,,,,23564.03,,,,,,,case rate,,18268.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18268.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26055.09,,,,,,,case rate,,27481.35,,,,,,,case rate,,23135.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18268.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17355.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18268.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18268.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18268.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19181.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18268.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18268.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18268.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19181.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18268.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18268.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18268.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24917.57,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24917.57,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18268.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18268.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27481.35,,facility
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,120,RC,,,,inpatient,,,,,10414.36,,,,,,,case rate,,7947.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7947.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11366.36,,,,,,,case rate,,11988.56,,,,,,,case rate,,10092.89,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7947.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7549.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7947.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7947.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7947.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8344.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7947.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7947.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7947.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8344.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7947.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7947.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7947.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10870.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10870.12,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7947.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7947.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,11988.56,,facility
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,120,RC,,,,inpatient,,,,,36087.45,,,,,,,case rate,,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39155.72,,,,,,,case rate,,41299.11,,,,,,,case rate,,34768.79,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27010.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29853.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29853.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37446.25,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37446.25,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28431.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,41299.11,,facility
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,120,RC,,,,inpatient,,,,,42855.73,,,,,,,case rate,,29966.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29966.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47211.2,,,,,,,case rate,,49795.55,,,,,,,case rate,,41921.75,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,29966.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28468.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29966.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29966.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29966.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31464.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29966.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29966.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29966.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31464.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29966.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29966.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29966.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45150.04,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45150.04,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29966.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29966.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,49795.55,,facility
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,120,RC,,,,inpatient,,,,,9926.61,,,,,,,case rate,,7329.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7329.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11663.61,,,,,,,case rate,,12302.08,,,,,,,case rate,,10356.85,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7329.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6962.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7329.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7329.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7329.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7329.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7329.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7329.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7695.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7329.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7329.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7329.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11154.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11154.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7329.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7329.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12302.08,,facility
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,120,RC,,,,inpatient,,,,,53146.64,,,,,,,case rate,,34914.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34914.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,57097.84,,,,,,,case rate,,60223.4,,,,,,,case rate,,50700.72,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,34914.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33168.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34914.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34914.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34914.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36660.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34914.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34914.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34914.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36660.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34914.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34914.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34914.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,54605.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,54605.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34914.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34914.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,60223.4,,facility
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,120,RC,,,,inpatient,,,,,27944.74,,,,,,,case rate,,20690.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20690.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30390.76,,,,,,,case rate,,32054.36,,,,,,,case rate,,26985.84,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20690.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19656.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20690.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20690.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20690.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21725.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20690.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20690.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20690.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21725.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20690.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20690.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20690.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29063.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29063.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20690.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20690.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32054.36,,facility
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,120,RC,,,,inpatient,,,,,14430.76,,,,,,,case rate,,10886.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10886.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15677.4,,,,,,,case rate,,16535.58,,,,,,,case rate,,13920.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10886.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10341.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10886.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10886.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10886.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11430.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10886.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10886.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10886.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11430.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10886.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10886.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10886.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14992.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14992.95,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10886.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10886.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16535.58,,facility
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,120,RC,,,,inpatient,,,,,9634.56,,,,,,,case rate,,7671.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7671.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10612.54,,,,,,,case rate,,11193.48,,,,,,,case rate,,9423.53,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7671.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7288.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7671.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7671.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7671.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8055.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7671.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7671.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7671.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8055.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7671.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7671.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7671.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10149.22,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10149.22,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7671.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7671.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,11193.48,,facility
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,120,RC,,,,inpatient,,,,,38360.6,,,,,,,case rate,,30520.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30520.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40798.02,,,,,,,case rate,,43031.31,,,,,,,case rate,,36227.09,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,30520.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28994.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30520.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30520.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30520.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32046.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30520.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30520.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30520.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32046.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30520.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30520.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30520.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39016.85,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39016.85,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30520.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30520.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,43031.31,,facility
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,120,RC,,,,inpatient,,,,,38163.4,,,,,,,case rate,,25206.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25206.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37033.86,,,,,,,case rate,,39061.11,,,,,,,case rate,,32884.67,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25206.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23946.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25206.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25206.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25206.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26466.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25206.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25206.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25206.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26466.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25206.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25206.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25206.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35417.03,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35417.03,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25206.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25206.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,39061.11,,facility
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,120,RC,,,,inpatient,,,,,13619.35,,,,,,,case rate,,10871,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10871,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 10230.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,11529,,,,,,,case rate,,12984,,,,,,,case rate,,12468.47,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10871,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10327.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10871,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10871,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17858,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10871,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17858,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11414.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10871,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10871,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10871,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2122,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1804,,,,,,,per diem,,11414.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10871,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10871,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10871,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 14228.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 16055.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,10871,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10871,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17858,,facility
DEPRESSIVE NEUROSES,881,MS-DRG,120,RC,,,,inpatient,,,,,13760.86,,,,,,,case rate,,10677.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10677.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14887.45,,,,,,,case rate,,15702.39,,,,,,,case rate,,13219.49,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10677.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10143.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10677.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10677.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10677.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11210.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10677.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10677.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10677.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11210.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10677.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10677.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10677.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14237.49,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14237.49,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10677.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10677.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15702.39,,facility
PANCREAS TRANSPLANT,010,MS-DRG,120,RC,,,,inpatient,,,,,120025.54,,,,,,,case rate,,78245.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,78245.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,79053.75,,,,,,,case rate,,83381.18,,,,,,,case rate,,70196.73,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,78245.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,74333.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78245.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78245.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78245.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,82157.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,78245.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78245.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,78245.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,82157.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,78245.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,78245.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78245.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,78245.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78245.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,120025.54,,facility
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,120,RC,,,,inpatient,,,,,12869.66,,,,,,,case rate,,8818.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8818.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10205.25,,,,,,,case rate,,10763.89,,,,,,,case rate,,9061.88,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8818.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8377.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8818.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8818.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8818.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9259.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8818.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8818.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8818.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9259.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8818.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8818.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8818.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9759.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9759.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8818.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8818.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12869.66,,facility
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,120,RC,,,,inpatient,,,,,25119.1,,,,,,,case rate,,20075.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20075.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30067.23,,,,,,,case rate,,31713.12,,,,,,,case rate,,26698.56,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20075.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19071.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20075.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20075.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20075.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21078.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20075.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20075.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20075.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21078.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20075.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20075.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20075.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28754.54,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28754.54,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20075.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20075.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,31713.12,,facility
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,120,RC,,,,inpatient,,,,,23523.38,,,,,,,case rate,,16676.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24849,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16676.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26061.66,,,,,,,case rate,,27488.28,,,,,,,case rate,,23141.76,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16676.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15842.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16676.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16676.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16676.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17510.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16676.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16676.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16676.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17510.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16676.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16676.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16676.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24923.85,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24923.85,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16676.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16676.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27488.28,,facility
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,120,RC,,,,inpatient,,,,,30327.79,,,,,,,case rate,,21405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32021.57,,,,,,,case rate,,33774.44,,,,,,,case rate,,28433.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20335.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22476.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22476.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30623.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30623.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,33774.44,,facility
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,120,RC,,,,inpatient,,,,,59156.2,,,,,,,case rate,,42365.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42365.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,61282.42,,,,,,,case rate,,64637.04,,,,,,,case rate,,54416.46,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,42365.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,40247.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42365.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42365.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42365.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44483.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42365.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42365.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42365.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,44483.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42365.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42365.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42365.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58606.94,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,58606.94,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42365.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42365.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,64637.04,,facility
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,120,RC,,,,inpatient,,,,,9929.62,,,,,,,case rate,,8158.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8158.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11088.81,,,,,,,case rate,,11695.81,,,,,,,case rate,,9846.44,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8158.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7750.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8158.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8158.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8158.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8566.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8158.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8158.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8158.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8566.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8158.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8158.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8158.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10604.69,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10604.69,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8158.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8158.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,11695.81,,facility
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,120,RC,,,,inpatient,,,,,13319.78,,,,,,,case rate,,9904.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9904.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15071.39,,,,,,,case rate,,15896.4,,,,,,,case rate,,13382.82,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9904.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9409.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9904.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9904.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9904.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10399.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9904.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9904.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9904.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10399.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9904.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9904.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9904.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14413.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14413.4,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9904.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9904.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15896.4,,facility
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,120,RC,,,,inpatient,,,,,70824.55,,,,,,,case rate,,52074.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,52074.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,80147.52,,,,,,,case rate,,84534.82,,,,,,,case rate,,71167.96,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,52074.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,49470.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52074.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52074.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52074.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,54678.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,52074.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52074.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,52074.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,54678.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,52074.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52074.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52074.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,76648.42,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,76648.42,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52074.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52074.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,84534.82,,facility
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,120,RC,,,,inpatient,,,,,26458.91,,,,,,,case rate,,19203.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19203.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28572.74,,,,,,,case rate,,30136.82,,,,,,,case rate,,25371.5,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19203.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18243.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19203.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19203.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19203.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20164.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19203.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19203.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19203.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20164.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19203.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19203.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19203.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27325.3,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27325.3,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19203.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19203.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30136.82,,facility
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,120,RC,,,,inpatient,,,,,95206.01,,,,,,,case rate,,66818.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,66818.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,112868.71,,,,,,,case rate,,119047.18,,,,,,,case rate,,100223.13,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,66818.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,63477.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66818.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66818.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66818.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,70159.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,66818.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66818.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,66818.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,70159.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,66818.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,66818.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66818.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107941.06,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,107941.06,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,66818.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66818.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,119047.18,,facility
PLEURAL EFFUSION WITH CC,187,MS-DRG,120,RC,,,,inpatient,,,,,15114.22,,,,,,,case rate,,11199.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11199.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16362.23,,,,,,,case rate,,17257.91,,,,,,,case rate,,14529.04,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11199.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10639.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11199.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11199.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11199.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11759.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11199.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11199.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11199.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11759.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11199.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11199.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11199.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15647.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15647.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11199.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11199.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17257.91,,facility
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,120,RC,,,,inpatient,,,,,18739.22,,,,,,,case rate,,14259.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14259.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20295.54,,,,,,,case rate,,21406.53,,,,,,,case rate,,18021.67,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14259.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13546.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14259.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14259.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14259.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14972.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14259.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14259.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14259.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14972.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14259.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14259.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14259.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19409.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19409.47,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14259.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14259.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,21406.53,,facility
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,120,RC,,,,inpatient,,,,,25929.01,,,,,,,case rate,,21260.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21260.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31430.34,,,,,,,case rate,,33150.84,,,,,,,case rate,,27908.95,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21260.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20197.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21260.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21260.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21260.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22323.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21260.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21260.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21260.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22323.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21260.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21260.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21260.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30058.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30058.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21260.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21260.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,33150.84,,facility
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,120,RC,,,,inpatient,,,,,8260.13,,,,,,,case rate,,6614.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6614.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9221.51,,,,,,,case rate,,9726.3,,,,,,,case rate,,8188.35,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,6614.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6283.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6614.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6614.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6614.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6944.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6614.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6614.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6614.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,6944.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6614.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6614.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6614.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8818.92,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8818.92,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6614.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6614.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,9726.3,,facility
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,120,RC,,,,inpatient,,,,,112366.07,,,,,,,case rate,,83059.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,83059.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,118779.35,,,,,,,case rate,,125281.37,,,,,,,case rate,,105471.55,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,83059.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,78906.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83059.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83059.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83059.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,87212.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,83059.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83059.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,83059.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,87212.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,83059.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,83059.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83059.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,113593.64,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,113593.64,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,83059.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83059.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,125281.37,,facility
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,120,RC,,,,inpatient,,,,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26730.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26730.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,26730.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25393.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26730.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26730.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26730.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28066.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26730.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26730.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26730.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28066.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26730.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26730.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26730.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26730.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26730.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28066.89,,facility
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,120,RC,,,,inpatient,,,,,23670.91,,,,,,,case rate,,17780.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17780.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25373.54,,,,,,,case rate,,26762.49,,,,,,,case rate,,22530.74,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17780.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16891.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17780.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17780.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17780.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18669.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17780.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17780.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17780.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18669.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17780.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17780.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17780.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24265.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24265.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17780.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17780.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26762.49,,facility
RENAL FAILURE WITH CC,683,MS-DRG,120,RC,,,,inpatient,,,,,13381.5,,,,,,,case rate,,9971.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9971.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14793.84,,,,,,,case rate,,15603.66,,,,,,,case rate,,13136.37,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9971.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9472.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9971.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9971.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9971.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10470.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9971.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9971.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9971.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10470.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9971.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9971.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9971.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14147.96,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14147.96,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9971.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9971.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15603.66,,facility
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,120,RC,,,,inpatient,,,,,13003.65,,,,,,,case rate,,10160.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10160.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14425.96,,,,,,,case rate,,15215.64,,,,,,,case rate,,12809.71,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10160.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9652.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10160.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10160.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10160.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10668.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10160.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10160.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10160.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10668.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10160.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10160.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10160.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13796.15,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13796.15,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10160.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10160.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15215.64,,facility
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,120,RC,,,,inpatient,,,,,12253.96,,,,,,,case rate,,9216.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9216.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13302.63,,,,,,,case rate,,14030.82,,,,,,,case rate,,11812.23,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9216.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8755.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9216.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9216.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9216.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9676.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9216.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9216.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9216.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9676.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9216.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9216.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9216.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12721.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12721.86,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9216.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9216.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14030.82,,facility
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,120,RC,,,,inpatient,,,,,15296.37,,,,,,,case rate,,11469.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11469.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16327.75,,,,,,,case rate,,17221.53,,,,,,,case rate,,14498.42,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11469.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10895.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11469.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11469.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11469.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12042.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11469.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11469.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11469.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12042.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11469.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11469.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11469.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15614.91,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15614.91,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11469.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11469.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17221.53,,facility
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,120,RC,,,,inpatient,,,,,14841.74,,,,,,,case rate,,11108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16156.95,,,,,,,case rate,,17041.38,,,,,,,case rate,,14346.76,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10552.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11663.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11663.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15451.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15451.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11108.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17041.38,,facility
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,120,RC,,,,inpatient,,,,,27136.34,,,,,,,case rate,,20011.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20011.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1843,,,,,,,per diem,,3909,,,,,,,per diem,,26532.31,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20011.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19010.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20011.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20011.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20011.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21011.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20011.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20011.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20011.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21011.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20011.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20011.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20011.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3796,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4352,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20011.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20011.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27136.34,,facility
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,120,RC,,,,inpatient,,,,,22541.86,,,,,,,case rate,,17557.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17557.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25238.87,,,,,,,case rate,,26620.45,,,,,,,case rate,,22411.15,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17557.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16679.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17557.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17557.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17557.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18435.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17557.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17557.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17557.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18435.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17557.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17557.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17557.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24136.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24136.98,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17557.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17557.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26620.45,,facility
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,120,RC,,,,inpatient,,,,,12261.48,,,,,,,case rate,,9204.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9204.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13394.6,,,,,,,case rate,,14127.82,,,,,,,case rate,,11893.89,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9204.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8744.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9204.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9204.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9204.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9664.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9204.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9204.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9204.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9664.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9204.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9204.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9204.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12809.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12809.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9204.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9204.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14127.82,,facility
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,120,RC,,,,inpatient,,,,,46762.24,,,,,,,case rate,,34612.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34612.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52218.57,,,,,,,case rate,,55077.03,,,,,,,case rate,,46368.11,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,34612.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32881.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34612.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34612.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34612.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36342.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34612.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34612.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34612.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36342.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34612.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34612.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34612.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49938.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49938.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34612.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34612.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,55077.03,,facility
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,120,RC,,,,inpatient,,,,,39893.1,,,,,,,case rate,,31711.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31711.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44107.25,,,,,,,case rate,,46521.7,,,,,,,case rate,,39165.56,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,31711.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30125.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31711.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31711.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31711.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33296.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31711.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31711.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31711.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33296.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31711.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31711.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31711.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,280816,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42181.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31711.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31711.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,280816,,facility
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,120,RC,,,,inpatient,,,,,37668.12,,,,,,,case rate,,28147.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28147.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40063.91,,,,,,,case rate,,42257.02,,,,,,,case rate,,35575.23,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,28147.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26740.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28147.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28147.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28147.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29555.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28147.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28147.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28147.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29555.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28147.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28147.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28147.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,38314.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38314.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28147.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28147.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,42257.02,,facility
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,120,RC,,,,inpatient,,,,,12067.29,,,,,,,case rate,,9039.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9039.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13079.28,,,,,,,case rate,,13795.24,,,,,,,case rate,,11613.9,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9039.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8587.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9039.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9039.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9039.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9491.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9039.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9039.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9039.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9491.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9039.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9039.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9039.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12508.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12508.26,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9039.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9039.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13795.24,,facility
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,120,RC,,,,inpatient,,,,,22665.3,,,,,,,case rate,,17541.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17541.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26621.68,,,,,,,case rate,,28078.96,,,,,,,case rate,,23639.04,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17541.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16664.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17541.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17541.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17541.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18418.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17541.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17541.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17541.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18418.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17541.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17541.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17541.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25459.43,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25459.43,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17541.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17541.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28078.96,,facility
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,120,RC,,,,inpatient,,,,,11722.55,,,,,,,case rate,,8806.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8806.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12496.26,,,,,,,case rate,,13180.31,,,,,,,case rate,,11096.2,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8806.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8366.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8806.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8806.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8806.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9246.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8806.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8806.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8806.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9246.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8806.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8806.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8806.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11950.7,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11950.7,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8806.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8806.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13180.31,,facility
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,120,RC,,,,inpatient,,,,,44153.38,,,,,,,case rate,,31930.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31930.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,48025.78,,,,,,,case rate,,50654.72,,,,,,,case rate,,42645.07,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,31930.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30333.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31930.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31930.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31930.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33526.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31930.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31930.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31930.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33526.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31930.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31930.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31930.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45929.06,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45929.06,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31930.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31930.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,50654.72,,facility
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,120,RC,,,,inpatient,,,,,20630,,,,,,,case rate,,16128.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16128.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21400.81,,,,,,,case rate,,22572.3,,,,,,,case rate,,19003.11,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16128.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15321.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16128.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16128.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16128.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16934.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16128.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16128.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16128.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16934.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16128.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16128.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16128.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20466.49,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20466.49,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16128.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16128.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22572.3,,facility
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,120,RC,,,,inpatient,,,,,13738.28,,,,,,,case rate,,10672.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10672.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15698.75,,,,,,,case rate,,16558.1,,,,,,,case rate,,13939.89,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10672.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10139.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10672.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10672.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10672.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11206.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10672.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10672.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10672.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11206.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10672.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10672.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10672.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15013.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15013.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10672.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10672.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16558.1,,facility
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,120,RC,,,,inpatient,,,,,18545.02,,,,,,,case rate,,15035.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15035.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19310.16,,,,,,,case rate,,20367.21,,,,,,,case rate,,17146.69,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15035.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14284,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15035.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15035.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15035.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15787.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15035.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15035.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15035.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15787.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15035.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15035.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15035.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18467.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18467.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15035.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15035.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20367.21,,facility
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,120,RC,,,,inpatient,,,,,24714.15,,,,,,,case rate,,21167.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21167.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29392.24,,,,,,,case rate,,31001.18,,,,,,,case rate,,26099.2,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,21167.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20109.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21167.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21167.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21167.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22225.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21167.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21167.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21167.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22225.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21167.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21167.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21167.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28109.03,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28109.03,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21167.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21167.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,31001.18,,facility
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,120,RC,,,,inpatient,,,,,11763.2,,,,,,,case rate,,8913.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8913.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12832.93,,,,,,,case rate,,13535.41,,,,,,,case rate,,11395.16,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8913.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8468.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8913.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8913.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8913.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9359.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8913.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8913.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8913.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9359.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8913.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8913.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8913.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12272.67,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12272.67,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8913.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8913.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13535.41,,facility
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,120,RC,,,,inpatient,,,,,35775.83,,,,,,,case rate,,26342.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26342.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38065.23,,,,,,,case rate,,40148.93,,,,,,,case rate,,33800.48,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,26342.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25025.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26342.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26342.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26342.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27659.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26342.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26342.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26342.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27659.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26342.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26342.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26342.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36403.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36403.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26342.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26342.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,40148.93,,facility
URETHRAL STRICTURE,697,MS-DRG,120,RC,,,,inpatient,,,,,15081.1,,,,,,,case rate,,12160.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12160.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18280.44,,,,,,,case rate,,19281.12,,,,,,,case rate,,16232.34,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12160.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11552.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12160.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12160.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12160.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12768.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12160.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12160.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12160.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12768.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12160.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12160.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12160.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17482.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17482.35,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12160.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12160.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,19281.12,,facility
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,120,RC,,,,inpatient,,,,,19991.71,,,,,,,case rate,,14954.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14954.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21599.53,,,,,,,case rate,,22781.89,,,,,,,case rate,,19179.56,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14954.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14206.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14954.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14954.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14954.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15702.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14954.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14954.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14954.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15702.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14954.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14954.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14954.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20656.53,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20656.53,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14954.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,959.18,959.18,959.18,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,14954.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22781.89,,facility
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,120,RC,,,,inpatient,,,,,23988.55,,,,,,,case rate,,17844.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17844.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26232.46,,,,,,,case rate,,27668.43,,,,,,,case rate,,23293.43,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17844.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16952.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17844.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17844.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17844.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18737.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17844.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17844.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17844.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18737.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17844.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17844.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17844.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25087.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25087.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17844.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17844.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27668.43,,facility
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,120,RC,,,,inpatient,,,,,27452.47,,,,,,,case rate,,20321.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20321.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29967.05,,,,,,,case rate,,31607.45,,,,,,,case rate,,26609.6,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20321.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19305.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20321.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20321.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20321.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21337.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20321.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20321.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20321.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21337.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20321.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20321.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20321.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28658.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28658.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20321.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20321.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,31607.45,,facility
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,120,RC,,,,inpatient,,,,,32656.64,,,,,,,case rate,,25350.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25350.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35383.35,,,,,,,case rate,,37320.25,,,,,,,case rate,,31419.07,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25350.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24083.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25350.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25350.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25350.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26618.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25350.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25350.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25350.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26618.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25350.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25350.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25350.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33838.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33838.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25350.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25350.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,37320.25,,facility
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,120,RC,,,,inpatient,,,,,61473.01,,,,,,,case rate,,46439.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46439.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,46439.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44117.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46439.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46439.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46439.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48761.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46439.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46439.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46439.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,48761.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46439.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46439.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46439.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46439.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46439.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,61473.01,,facility
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,120,RC,,,,inpatient,,,,,18951.48,,,,,,,case rate,,14664.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14664.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21372.89,,,,,,,case rate,,22542.85,,,,,,,case rate,,18978.32,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14664.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13930.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14664.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14664.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14664.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15397.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14664.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14664.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14664.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15397.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14664.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14664.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14664.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20439.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20439.79,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14664.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14664.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22542.85,,facility
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,120,RC,,,,inpatient,,,,,56332.07,,,,,,,case rate,,39052.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39052.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,62827.83,,,,,,,case rate,,66267.04,,,,,,,case rate,,55788.72,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,39052.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37099.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39052.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39052.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39052.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41005.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39052.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39052.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39052.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41005.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39052.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39052.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39052.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60084.87,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,60084.87,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39052.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39052.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,66267.04,,facility
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,120,RC,,,,inpatient,,,,,24650.92,,,,,,,case rate,,19085.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19085.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28034.06,,,,,,,case rate,,29568.65,,,,,,,case rate,,24893.18,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19085.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18131.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19085.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19085.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19085.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20040,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19085.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19085.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19085.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20040,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19085.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19085.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19085.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26810.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26810.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19085.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19085.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29568.65,,facility
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,120,RC,,,,inpatient,,,,,38444.91,,,,,,,case rate,,28575.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28575.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40137.81,,,,,,,case rate,,42334.97,,,,,,,case rate,,35640.85,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,28575.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27147.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28575.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28575.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28575.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30004.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28575.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28575.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28575.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30004.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28575.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28575.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28575.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,38385.46,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38385.46,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28575.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28575.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,42334.97,,facility
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,120,RC,,,,inpatient,,,,,62782.71,,,,,,,case rate,,45667.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,45667.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1843,,,,,,,per diem,,3909,,,,,,,per diem,,61384.22,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,45667.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,43384.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45667.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45667.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45667.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47950.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,45667.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45667.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,45667.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,47950.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,45667.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45667.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45667.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3796,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4352,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45667.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,45667.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,62782.71,,facility
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,120,RC,,,,inpatient,,,,,106386.62,,,,,,,case rate,,77754.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,77754.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,115548.94,,,,,,,case rate,,121874.13,,,,,,,case rate,,102603.07,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,77754.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,73866.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,77754.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,77754.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,77754.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,81642.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,77754.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,77754.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,77754.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,81642.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,77754.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,77754.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,77754.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110504.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,110504.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,77754.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,77754.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,121874.13,,facility
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,120,RC,,,,inpatient,,,,,19389.55,,,,,,,case rate,,13042.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13042.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19265.82,,,,,,,case rate,,20320.44,,,,,,,case rate,,17107.32,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13042.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12390.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13042.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13042.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13042.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13694.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13042.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13042.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13042.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13694.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13042.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13042.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13042.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18424.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18424.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13042.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13042.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20320.44,,facility
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,120,RC,,,,inpatient,,,,,17083.28,,,,,,,case rate,,13292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19513.81,,,,,,,case rate,,20582,,,,,,,case rate,,17327.52,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12627.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13956.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13956.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18661.87,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18661.87,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13292.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20582,,facility
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,120,RC,,,,inpatient,,,,,40563,,,,,,,case rate,,28470.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28470.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45005.59,,,,,,,case rate,,47469.21,,,,,,,case rate,,39963.25,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,28470.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27047.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28470.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28470.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28470.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29894.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28470.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28470.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28470.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29894.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28470.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28470.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28470.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,43040.72,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,43040.72,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28470.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28470.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,47469.21,,facility
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,120,RC,,,,inpatient,,,,,18352.33,,,,,,,case rate,,13155.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13155.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20389.15,,,,,,,case rate,,21505.26,,,,,,,case rate,,18104.79,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13155.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12497.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13155.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13155.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13155.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13813.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13155.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13155.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13155.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13813.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13155.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13155.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13155.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19499,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19499,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13155.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13155.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,21505.26,,facility
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,120,RC,,,,inpatient,,,,,61117.73,,,,,,,case rate,,44468.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,44468.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1843,,,,,,,per diem,,3909,,,,,,,per diem,,59756.76,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,44468.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,42245.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44468.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44468.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44468.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,46692.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,44468.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44468.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,44468.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46692.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,44468.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44468.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44468.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3796,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4352,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44468.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44468.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,61117.73,,facility
PNEUMOTHORAX WITH MCC,199,MS-DRG,120,RC,,,,inpatient,,,,,26574.83,,,,,,,case rate,,19598.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19598.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29136.04,,,,,,,case rate,,30730.96,,,,,,,case rate,,25871.7,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19598.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18618.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19598.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19598.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19598.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20578.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19598.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19598.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19598.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20578.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19598.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19598.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19598.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27864.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27864.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19598.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19598.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30730.96,,facility
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,120,RC,,,,inpatient,,,,,212713.02,,,,,,,case rate,,150592.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,354666,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,150592.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,241418.1,,,,,,,case rate,,254633.4,,,,,,,case rate,,214370.1,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,150592.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,143062.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,150592.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,150592.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,150592.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,158122.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,150592.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,150592.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,150592.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,158122.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,150592.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,150592.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,150592.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,280816,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,230878.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,150592.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,150592.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,354666,,facility
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,120,RC,,,,inpatient,,,,,15318.95,,,,,,,case rate,,11319.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11319.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16230.85,,,,,,,case rate,,17119.33,,,,,,,case rate,,14412.38,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11319.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10753.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11319.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11319.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11319.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11885.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11319.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11319.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11319.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11885.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11319.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11319.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11319.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15522.24,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15522.24,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11319.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11319.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17119.33,,facility
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,120,RC,,,,inpatient,,,,,52275.02,,,,,,,case rate,,40641.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40641.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,56797.3,,,,,,,case rate,,59906.4,,,,,,,case rate,,50433.85,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,40641.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,38609.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40641.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40641.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40641.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,42673.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,40641.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40641.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40641.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42673.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,40641.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40641.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40641.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,54317.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,54317.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40641.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40641.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,59906.4,,facility
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,120,RC,,,,inpatient,,,,,75825.49,,,,,,,case rate,,53818.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,53818.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,78942.08,,,,,,,case rate,,83263.39,,,,,,,case rate,,70097.56,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,53818.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51127.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53818.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53818.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53818.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,56509.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,53818.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53818.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,53818.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,56509.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,53818.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53818.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53818.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,75495.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,75495.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,53818.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53818.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,83263.39,,facility
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,120,RC,,,,inpatient,,,,,24709.64,,,,,,,case rate,,17864.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35703,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17864.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26055.09,,,,,,,case rate,,27481.35,,,,,,,case rate,,23135.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17864.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16971.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17864.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17864.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17864.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18757.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17864.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17864.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17864.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18757.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17864.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17864.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17864.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24917.57,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24917.57,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17864.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17864.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,35703,,facility
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,120,RC,,,,inpatient,,,,,28363.24,,,,,,,case rate,,20932.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20932.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31128.15,,,,,,,case rate,,32832.12,,,,,,,case rate,,27640.62,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20932.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19885.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20932.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20932.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20932.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21979,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20932.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20932.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20932.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21979,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20932.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20932.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20932.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29769.15,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29769.15,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20932.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20932.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32832.12,,facility
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,120,RC,,,,inpatient,,,,,26135.25,,,,,,,case rate,,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30724.15,,,,,,,case rate,,32406,,,,,,,case rate,,27281.88,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19232.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21256.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21256.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29382.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29382.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20244.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32406,,facility
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,120,RC,,,,inpatient,,,,,10543.82,,,,,,,case rate,,8241.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8241.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12780.38,,,,,,,case rate,,13479.98,,,,,,,case rate,,11348.49,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8241.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7829.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8241.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8241.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8241.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8653.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8241.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8241.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8241.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8653.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8241.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8241.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8241.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12222.41,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12222.41,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8241.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8241.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13479.98,,facility
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,120,RC,,,,inpatient,,,,,25496.96,,,,,,,case rate,,18880.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18880.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26928.79,,,,,,,case rate,,28402.88,,,,,,,case rate,,23911.75,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18880.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17936.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18880.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18880.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18880.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19824.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18880.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18880.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18880.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19824.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18880.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18880.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18880.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25753.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25753.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18880.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18880.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28402.88,,facility
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,120,RC,,,,inpatient,,,,,15350.56,,,,,,,case rate,,11040.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11040.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16413.15,,,,,,,case rate,,17311.61,,,,,,,case rate,,14574.25,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11040.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10488.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11040.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11040.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11040.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11592.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11040.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11040.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11040.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11592.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11040.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11040.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11040.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15696.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15696.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11040.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11040.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17311.61,,facility
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,120,RC,,,,inpatient,,,,,18746.75,,,,,,,case rate,,13335.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13335.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21149.54,,,,,,,case rate,,22307.27,,,,,,,case rate,,18779.99,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13335.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12668.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13335.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13335.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13335.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14002.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13335.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13335.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13335.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14002.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13335.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13335.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13335.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20226.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20226.19,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13335.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13335.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22307.27,,facility
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,120,RC,,,,inpatient,,,,,26335.47,,,,,,,case rate,,19789.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19789.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28495.55,,,,,,,case rate,,30055.4,,,,,,,case rate,,25302.96,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19789.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18799.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19789.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19789.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19789.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20778.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19789.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19789.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19789.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20778.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19789.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19789.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19789.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27251.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27251.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19789.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19789.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30055.4,,facility
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,120,RC,,,,inpatient,,,,,11707.5,,,,,,,case rate,,9003.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9003.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12410.86,,,,,,,case rate,,13090.24,,,,,,,case rate,,11020.37,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9003.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8553.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9003.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9003.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9003.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9453.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9003.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9003.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9003.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9453.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9003.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9003.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9003.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11869.02,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11869.02,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9003.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9003.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13090.24,,facility
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,120,RC,,,,inpatient,,,,,157696.67,,,,,,,case rate,,119920.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,119920.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,119920.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,113924.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119920.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119920.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119920.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,125916.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,119920.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119920.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,119920.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,125916.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,119920.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,119920.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119920.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,119920.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119920.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,157696.67,,facility
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,120,RC,,,,inpatient,,,,,24854.15,,,,,,,case rate,,18718.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18718.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27459.26,,,,,,,case rate,,28962.38,,,,,,,case rate,,24382.78,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18718.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17782.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18718.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18718.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18718.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19654.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18718.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18718.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18718.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19654.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18718.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18718.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18718.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26260.43,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26260.43,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18718.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18718.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28962.38,,facility
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,120,RC,,,,inpatient,,,,,63666.38,,,,,,,case rate,,46704.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46704.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,62047.74,,,,,,,case rate,,65444.25,,,,,,,case rate,,55096.03,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,46704.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44369.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46704.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46704.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46704.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,49039.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46704.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46704.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,46704.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,49039.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46704.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46704.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46704.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59338.84,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,59338.84,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46704.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46704.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,65444.25,,facility
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,120,RC,,,,inpatient,,,,,42234,,,,,,,case rate,,34532.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34532.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44483.34,,,,,,,case rate,,46918.37,,,,,,,case rate,,39499.51,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,34532.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32805.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34532.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34532.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34532.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36258.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34532.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34532.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,34532.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36258.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,34532.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34532.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34532.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42541.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42541.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34532.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,34532.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,46918.37,,facility
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,120,RC,,,,inpatient,,,,,51852,,,,,,,case rate,,39020.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39020.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,56761.17,,,,,,,case rate,,59868.3,,,,,,,case rate,,50401.76,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,39020.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37069.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39020.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39020.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39020.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,40972.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39020.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39020.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,39020.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40972.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39020.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39020.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39020.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,54283.08,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,54283.08,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39020.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39020.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,59868.3,,facility
SALIVARY GLAND PROCEDURES,139,MS-DRG,120,RC,,,,inpatient,,,,,20669.14,,,,,,,case rate,,13871.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13871.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19505.6,,,,,,,case rate,,20573.34,,,,,,,case rate,,17320.23,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13871.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13178.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13871.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13871.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13871.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14565.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13871.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13871.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13871.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14565.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13871.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13871.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13871.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18654.02,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18654.02,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13871.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13871.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20669.14,,facility
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,120,RC,,,,inpatient,,,,,27167.95,,,,,,,case rate,,20068.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49652,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20068.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30045.88,,,,,,,case rate,,31690.6,,,,,,,case rate,,26679.6,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20068.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19065.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20068.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20068.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20068.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21072.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20068.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20068.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20068.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21072.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20068.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20068.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20068.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28734.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28734.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20068.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20068.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,49652,,facility
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,120,RC,,,,inpatient,,,,,16079.18,,,,,,,case rate,,12012.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12012.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17275.35,,,,,,,case rate,,18221.01,,,,,,,case rate,,15339.86,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,12012.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11411.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12012.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12012.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12012.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12612.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12012.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12012.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12012.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12612.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12012.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12012.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12012.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16521.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16521.14,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12012.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12012.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18221.01,,facility
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,120,RC,,,,inpatient,,,,,31271.67,,,,,,,case rate,,23418.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23418.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34616.4,,,,,,,case rate,,36511.31,,,,,,,case rate,,30738.05,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23418.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22247.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23418.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23418.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23418.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24589.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23418.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23418.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23418.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24589.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23418.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23418.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23418.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33105.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33105.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23418.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23418.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36511.31,,facility
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,120,RC,,,,inpatient,,,,,66129.21,,,,,,,case rate,,48846.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,48846.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,71635.48,,,,,,,case rate,,75556.83,,,,,,,case rate,,63609.59,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,48846.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,46403.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,48846.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,48846.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,48846.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51288.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,48846.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,48846.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,48846.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,51288.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,48846.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48846.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,48846.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,68508,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,68508,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,48846.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,48846.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,75556.83,,facility
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,120,RC,,,,inpatient,,,,,100932.55,,,,,,,case rate,,72890.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,72890.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,72890.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,69246.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72890.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72890.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72890.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,76535.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,72890.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72890.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,72890.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,76535.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,72890.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,72890.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72890.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,72890.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,72890.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,100932.55,,facility
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,120,RC,,,,inpatient,,,,,19642.46,,,,,,,case rate,,14393.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14393.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21085.49,,,,,,,case rate,,22239.72,,,,,,,case rate,,18723.11,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14393.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13673.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14393.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14393.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14393.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15112.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14393.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14393.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14393.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15112.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14393.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14393.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14393.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20164.93,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20164.93,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14393.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14393.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22239.72,,facility
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,120,RC,,,,inpatient,,,,,11293.51,,,,,,,case rate,,8675.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8675.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12859.21,,,,,,,case rate,,13563.13,,,,,,,case rate,,11418.49,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,8675.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8241.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8675.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8675.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8675.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9109.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8675.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8675.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8675.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9109.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8675.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8675.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8675.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12297.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12297.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8675.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8675.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13563.13,,facility
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,120,RC,,,,inpatient,,,,,49706.8,,,,,,,case rate,,41083.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41083.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,54616.33,,,,,,,case rate,,57606.04,,,,,,,case rate,,48497.22,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,41083.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,39029.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,41083.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,41083.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,41083.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,43137.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,41083.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,41083.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41083.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,43137.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,41083.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41083.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,41083.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52231.87,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52231.87,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41083.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,41083.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,57606.04,,facility
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,120,RC,,,,inpatient,,,,,57230.79,,,,,,,case rate,,42874.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42874.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,62223.46,,,,,,,case rate,,65629.59,,,,,,,case rate,,55252.07,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,42874.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,40730.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42874.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42874.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42874.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,45018.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42874.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42874.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42874.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,45018.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42874.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42874.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42874.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59506.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,59506.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42874.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42874.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,65629.59,,facility
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,120,RC,,,,inpatient,,,,,28762.17,,,,,,,case rate,,23063.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23063.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34864.39,,,,,,,case rate,,36772.87,,,,,,,case rate,,30958.25,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23063.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21909.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23063.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23063.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23063.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24216.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23063.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23063.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23063.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24216.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23063.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23063.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23063.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33342.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33342.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23063.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23063.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36772.87,,facility
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,120,RC,,,,inpatient,,,,,90864.44,,,,,,,case rate,,64742.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,64742.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,101444.87,,,,,,,case rate,,106997.99,,,,,,,case rate,,90079.19,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,64742.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,61505.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64742.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64742.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64742.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,67979.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64742.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64742.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,64742.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,67979.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64742.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64742.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64742.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,64742.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64742.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,106997.99,,facility
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,120,RC,,,,inpatient,,,,,37150.26,,,,,,,case rate,,27821.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27821.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39955.52,,,,,,,case rate,,42142.69,,,,,,,case rate,,35478.98,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,27821.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26430.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27821.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27821.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27821.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29212.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27821.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27821.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27821.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29212.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27821.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27821.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27821.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,38211.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38211.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27821.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27821.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,42142.69,,facility
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,120,RC,,,,inpatient,,,,,106924.05,,,,,,,case rate,,78710.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,78710.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,78710.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,74775.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78710.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78710.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78710.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,82646.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,78710.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78710.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,78710.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,82646.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,78710.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,78710.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78710.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,78710.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78710.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,106924.05,,facility
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,120,RC,,,,inpatient,,,,,45315.55,,,,,,,case rate,,32353.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32353.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47991.29,,,,,,,case rate,,50618.35,,,,,,,case rate,,42614.44,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,32353.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30736.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32353.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32353.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32353.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33971.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32353.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32353.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,32353.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,33971.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32353.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32353.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32353.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45896.07,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45896.07,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32353.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32353.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,50618.35,,facility
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,120,RC,,,,inpatient,,,,,24325.76,,,,,,,case rate,,18356.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18356.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 10230.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,11529,,,,,,,case rate,,12984,,,,,,,case rate,,25512.96,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18356.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17438.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18356.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18356.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17858,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18356.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17858,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19274.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18356.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18356.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18356.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2122,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1804,,,,,,,per diem,,19274.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18356.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18356.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18356.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 14228.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Outlier Per Diem Second Dollar + Days Threshold 4.00 + Fixed Amount 16055.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,18356.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18356.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25512.96,,facility
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,120,RC,,,,inpatient,,,,,26445.36,,,,,,,case rate,,19260.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19260.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28420,,,,,,,case rate,,29975.72,,,,,,,case rate,,25235.88,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,19260.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18297.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19260.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19260.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19260.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20223.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19260.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19260.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19260.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20223.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,19260.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19260.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19260.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27179.23,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27179.23,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19260.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,19260.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29975.72,,facility
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,120,RC,,,,inpatient,,,,,22317.56,,,,,,,case rate,,17106.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17106.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23952.95,,,,,,,case rate,,25264.14,,,,,,,case rate,,21269.31,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17106.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16251.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17106.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17106.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17106.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17962.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17106.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17106.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17106.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17962.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17106.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17106.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17106.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22907.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22907.2,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17106.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17106.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25264.14,,facility
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,120,RC,,,,inpatient,,,,,81220.85,,,,,,,case rate,,53596.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,53596.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,93333.55,,,,,,,case rate,,98442.66,,,,,,,case rate,,82876.65,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,53596.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,50916.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53596.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53596.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53596.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,56275.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,53596.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53596.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,53596.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,56275.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,53596.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53596.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53596.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,89258.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,89258.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,53596.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53596.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,98442.66,,facility
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,120,RC,,,,inpatient,,,,,21665.72,,,,,,,case rate,,16119.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16119.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22116.85,,,,,,,case rate,,23327.54,,,,,,,case rate,,19638.93,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16119.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15313.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16119.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16119.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16119.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16925.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16119.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16119.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16119.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16925.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16119.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16119.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16119.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21151.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21151.27,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16119.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16119.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23327.54,,facility
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,120,RC,,,,inpatient,,,,,33996.45,,,,,,,case rate,,24726.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24726.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36253.77,,,,,,,case rate,,38238.32,,,,,,,case rate,,32191.97,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,24726.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23490.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24726.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24726.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24726.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25962.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24726.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24726.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24726.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25962.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24726.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24726.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24726.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,34671,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,34671,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24726.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24726.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,38238.32,,facility
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,120,RC,,,,inpatient,,,,,21796.69,,,,,,,case rate,,15821.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15821.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26421.32,,,,,,,case rate,,27867.63,,,,,,,case rate,,23461.13,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15821.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15030.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15821.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15821.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15821.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16612.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15821.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15821.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15821.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16612.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15821.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15821.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15821.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25267.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25267.81,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15821.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15821.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,27867.63,,facility
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,120,RC,,,,inpatient,,,,,19362.45,,,,,,,case rate,,14237.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14237.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20555.03,,,,,,,case rate,,21680.22,,,,,,,case rate,,18252.08,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14237.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13525.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14237.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14237.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14237.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14948.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14237.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14237.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14237.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14948.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14237.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14237.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14237.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19657.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19657.63,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14237.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14237.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,21680.22,,facility
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,120,RC,,,,inpatient,,,,,11155.01,,,,,,,case rate,,7981.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7981.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12148.09,,,,,,,case rate,,12813.08,,,,,,,case rate,,10787.05,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7981.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7582.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7981.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7981.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7981.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8380.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7981.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7981.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7981.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8380.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7981.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7981.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7981.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11617.73,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11617.73,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7981.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7981.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,12813.08,,facility
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,120,RC,,,,inpatient,,,,,46983.53,,,,,,,case rate,,36153.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24849,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36153.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,53223.66,,,,,,,case rate,,56137.14,,,,,,,case rate,,47260.59,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,36153.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,34345.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36153.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36153.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36153.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37961.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,36153.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36153.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36153.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,37961.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,36153.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36153.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36153.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50900,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50900,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36153.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36153.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,56137.14,,facility
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,120,RC,,,,inpatient,,,,,12082.34,,,,,,,case rate,,9252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13251.72,,,,,,,case rate,,13977.12,,,,,,,case rate,,11767.02,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8790.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9715.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9715.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12673.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12673.17,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9252.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13977.12,,facility
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,120,RC,,,,inpatient,,,,,10968.34,,,,,,,case rate,,7586.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7586.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13294.42,,,,,,,case rate,,14022.16,,,,,,,case rate,,11804.94,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7586.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7206.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7586.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7586.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7586.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7965.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7586.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7586.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7586.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7965.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7586.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7586.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7586.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12714.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12714.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7586.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7586.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14022.16,,facility
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,120,RC,,,,inpatient,,,,,18045.23,,,,,,,case rate,,13926.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13926.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19083.53,,,,,,,case rate,,20128.16,,,,,,,case rate,,16945.45,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13926.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13229.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13926.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13926.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13926.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14622.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13926.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13926.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13926.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14622.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13926.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13926.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13926.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18250.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18250.37,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13926.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13926.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20128.16,,facility
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,120,RC,,,,inpatient,,,,,40696.98,,,,,,,case rate,,30359.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30359.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46030.38,,,,,,,case rate,,48550.1,,,,,,,case rate,,40873.23,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,30359.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28841.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30359.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30359.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30359.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31877.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30359.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30359.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30359.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,31877.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,30359.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30359.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30359.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44020.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,44020.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30359.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,30359.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,48550.1,,facility
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,120,RC,,,,inpatient,,,,,22582.51,,,,,,,case rate,,17089.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17089.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24650.92,,,,,,,case rate,,26000.32,,,,,,,case rate,,21889.08,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17089.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16235,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17089.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17089.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17089.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17943.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17089.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17089.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17089.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17943.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17089.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17089.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17089.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23574.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23574.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17089.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17089.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26000.32,,facility
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,120,RC,,,,inpatient,,,,,13870.76,,,,,,,case rate,,11092.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11092.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16156.95,,,,,,,case rate,,17041.38,,,,,,,case rate,,14346.76,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11092.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10537.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11092.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11092.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11092.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11646.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11092.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11092.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11092.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11646.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11092.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11092.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11092.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15451.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15451.56,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11092.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11092.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17041.38,,facility
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,120,RC,,,,inpatient,,,,,29420.03,,,,,,,case rate,,22455.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22455.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,30481.09,,,,,,,case rate,,32149.63,,,,,,,case rate,,27066.05,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,22455.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21332.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22455.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22455.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22455.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23577.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22455.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22455.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,22455.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23577.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22455.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22455.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22455.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29150.34,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29150.34,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22455.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22455.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,32149.63,,facility
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,120,RC,,,,inpatient,,,,,53965.58,,,,,,,case rate,,43657.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,43657.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55678.9,,,,,,,case rate,,58726.78,,,,,,,case rate,,49440.74,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,43657.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41474.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,43657.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,43657.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,43657.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,45840.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,43657.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,43657.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,43657.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,45840.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,43657.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,43657.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,43657.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53248.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,53248.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,43657.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,43657.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,58726.78,,facility
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,120,RC,,,,inpatient,,,,,21212.59,,,,,,,case rate,,15366.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15366.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23041.47,,,,,,,case rate,,24302.77,,,,,,,case rate,,20459.95,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15366.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14598.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15366.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15366.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15366.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16134.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15366.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15366.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15366.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16134.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15366.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15366.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15366.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22035.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22035.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15366.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15366.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,24302.77,,facility
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,120,RC,,,,inpatient,,,,,145287.66,,,,,,,case rate,,106499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,106499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,159390.14,,,,,,,case rate,,168115.21,,,,,,,case rate,,141532.39,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,106499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,101174.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,106499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,106499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,106499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,111824.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,106499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,106499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,106499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,111824.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,106499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,106499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,106499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,152431.44,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,152431.44,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,106499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,106499.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,168115.21,,facility
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,120,RC,,,,inpatient,,,,,25143.19,,,,,,,case rate,,17916.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17916.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28853.57,,,,,,,case rate,,30433.02,,,,,,,case rate,,25620.87,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,17916.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17020.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17916.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17916.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17916.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18812.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17916.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17916.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17916.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18812.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17916.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17916.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17916.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27593.87,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27593.87,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17916.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17916.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30433.02,,facility
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,120,RC,,,,inpatient,,,,,104723.15,,,,,,,case rate,,75385.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,75385.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,114384.55,,,,,,,case rate,,120646,,,,,,,case rate,,101569.14,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,75385.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,71616.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75385.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75385.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75385.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,79154.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,75385.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75385.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,75385.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,79154.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,75385.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,75385.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75385.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,109390.72,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,109390.72,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,75385.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,75385.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,120646,,facility
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,120,RC,,,,inpatient,,,,,16104.77,,,,,,,case rate,,11926.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11926.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16932.11,,,,,,,case rate,,17858.98,,,,,,,case rate,,15035.07,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11926.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11330.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11926.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11926.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11926.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12522.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11926.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11926.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11926.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12522.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11926.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11926.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11926.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16192.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16192.89,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11926.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11926.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17858.98,,facility
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,120,RC,,,,inpatient,,,,,53459.76,,,,,,,case rate,,40270.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40270.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,56858.07,,,,,,,case rate,,59970.5,,,,,,,case rate,,50487.8,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,40270.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,38257.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40270.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40270.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40270.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,42284.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,40270.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40270.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,40270.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42284.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,40270.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40270.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40270.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,54375.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,54375.74,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40270.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,40270.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,59970.5,,facility
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,120,RC,,,,inpatient,,,,,9259.72,,,,,,,case rate,,7214.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7214.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10110,,,,,,,case rate,,10663.42,,,,,,,case rate,,8977.29,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,7214.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6853.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7214.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7214.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7214.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7575.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7214.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7214.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7214.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,7575.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7214.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7214.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7214.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9668.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9668.61,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7214.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7214.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,10663.42,,facility
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,120,RC,,,,inpatient,,,,,17835.98,,,,,,,case rate,,13509.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13509.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20054.13,,,,,,,case rate,,21151.89,,,,,,,case rate,,17807.3,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13509.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12834.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13509.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13509.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13509.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14185.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13509.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13509.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13509.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14185.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13509.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13509.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13509.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19178.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19178.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13509.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13509.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,21151.89,,facility
SPINAL PROCEDURES WITH MCC,028,MS-DRG,120,RC,,,,inpatient,,,,,91520.79,,,,,,,case rate,,65594.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,65594.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,98966.64,,,,,,,case rate,,104384.1,,,,,,,case rate,,87878.62,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,65594.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,62314.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65594.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65594.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65594.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,68873.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,65594.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65594.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,65594.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,68873.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,65594.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,65594.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65594.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,94645.93,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,94645.93,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,65594.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,65594.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,104384.1,,facility
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,120,RC,,,,inpatient,,,,,14935.07,,,,,,,case rate,,11057.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11057.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16204.57,,,,,,,case rate,,17091.62,,,,,,,case rate,,14389.05,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11057.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10504.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11057.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11057.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11057.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11610.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11057.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11057.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11057.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11610.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11057.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11057.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11057.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15497.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15497.11,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11057.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11057.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17091.62,,facility
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,120,RC,,,,inpatient,,,,,76459.27,,,,,,,case rate,,54530.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,54530.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,83412.42,,,,,,,case rate,,87978.44,,,,,,,case rate,,74067.06,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,54530.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51803.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54530.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54530.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54530.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,57256.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,54530.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54530.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,54530.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,57256.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,54530.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,54530.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54530.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,79770.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,79770.77,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,54530.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,54530.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,87978.44,,facility
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,120,RC,,,,inpatient,,,,,117668.09,,,,,,,case rate,,83333.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,83333.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,128092.83,,,,,,,case rate,,135104.67,,,,,,,case rate,,113741.57,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,83333.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,79167.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83333.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83333.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83333.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,87500.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,83333.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83333.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,83333.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,87500.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,83333.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,83333.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83333.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,122500.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,122500.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,83333.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,83333.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,135104.67,,facility
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,120,RC,,,,inpatient,,,,,19660.52,,,,,,,case rate,,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22195.68,,,,,,,case rate,,23410.68,,,,,,,case rate,,19708.92,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13802.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15255.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15255.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21226.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21226.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14528.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,23410.68,,facility
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,120,RC,,,,inpatient,,,,,27499.14,,,,,,,case rate,,20364.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20364.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29264.14,,,,,,,case rate,,30866.07,,,,,,,case rate,,25985.45,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,20364.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19346.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20364.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20364.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20364.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21382.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20364.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20364.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20364.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,21382.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20364.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20364.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20364.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27986.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27986.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20364.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20364.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,30866.07,,facility
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,120,RC,,,,inpatient,,,,,19217.94,,,,,,,case rate,,13127.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13127.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 3.00 + Fixed Amount 8669.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,7842,,,,,,,case rate,,8095,,,,,,,case rate,,20684.53,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13127.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12470.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13127.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13127.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13127.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13783.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13127.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13127.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13127.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2122,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1804,,,,,,,per diem,,13783.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13127.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13127.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13127.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Outlier Per Diem Second Dollar + Days Threshold 2.00 + Fixed Amount 11638.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Outlier Per Diem Second Dollar + Days Threshold 2.00 + Fixed Amount 13781.00,,,,0,other,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,13127.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13127.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20684.53,,facility
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,120,RC,,,,inpatient,,,,,32801.16,,,,,,,case rate,,23688.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23688.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35074.6,,,,,,,case rate,,36994.6,,,,,,,case rate,,31144.91,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23688.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22503.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23688.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23688.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23688.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24872.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23688.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23688.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23688.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24872.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23688.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23688.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23688.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33543.3,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33543.3,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23688.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23688.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,36994.6,,facility
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,120,RC,,,,inpatient,,,,,57542.41,,,,,,,case rate,,41261.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41261.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,63691.68,,,,,,,case rate,,67178.18,,,,,,,case rate,,56555.79,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,41261.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,39198.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,41261.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,41261.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,41261.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,43324.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,41261.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,41261.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,41261.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,43324.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,41261.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,41261.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,41261.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60911.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,60911.01,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41261.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,41261.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,67178.18,,facility
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,120,RC,,,,inpatient,,,,,25832.66,,,,,,,case rate,,18292.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18292.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27869.83,,,,,,,case rate,,29395.43,,,,,,,case rate,,24747.35,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18292.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17377.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18292.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18292.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18292.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19207.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18292.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18292.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18292.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19207.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18292.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18292.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18292.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26653.08,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26653.08,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18292.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18292.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,29395.43,,facility
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,120,RC,,,,inpatient,,,,,32475.99,,,,,,,case rate,,25142.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25142.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35222.41,,,,,,,case rate,,37150.49,,,,,,,case rate,,31276.16,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25142.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23885.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25142.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25142.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25142.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26399.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25142.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25142.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25142.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26399.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25142.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25142.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25142.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33684.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33684.66,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25142.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25142.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,37150.49,,facility
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,120,RC,,,,inpatient,,,,,22120.35,,,,,,,case rate,,16550.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16550.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26621.68,,,,,,,case rate,,28078.96,,,,,,,case rate,,23639.04,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16550.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15723.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16550.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16550.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16550.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17378.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16550.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16550.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16550.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17378.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16550.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16550.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16550.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25459.43,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25459.43,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16550.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16550.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,28078.96,,facility
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,120,RC,,,,inpatient,,,,,13316.77,,,,,,,case rate,,9768.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9768.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14138.56,,,,,,,case rate,,14912.51,,,,,,,case rate,,12554.5,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9768.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9280.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9768.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9768.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9768.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10257.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9768.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9768.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9768.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10257.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9768.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9768.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9768.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13521.3,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13521.3,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9768.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9768.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14912.51,,facility
EPISTAXIS WITH MCC,150,MS-DRG,120,RC,,,,inpatient,,,,,20807.64,,,,,,,case rate,,14910.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14910.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21588.03,,,,,,,case rate,,22769.77,,,,,,,case rate,,19169.35,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14910.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14164.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14910.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14910.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14910.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15655.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14910.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14910.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14910.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15655.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14910.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14910.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14910.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20645.54,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20645.54,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14910.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14910.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22769.77,,facility
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,120,RC,,,,inpatient,,,,,18528.46,,,,,,,case rate,,15104.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15104.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21208.66,,,,,,,case rate,,22369.63,,,,,,,case rate,,18832.49,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15104.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14348.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15104.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15104.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15104.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15859.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15104.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15104.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15104.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15859.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15104.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15104.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15104.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20282.73,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20282.73,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15104.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15104.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22369.63,,facility
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,120,RC,,,,inpatient,,,,,30284.13,,,,,,,case rate,,23001.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23001.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,33516.06,,,,,,,case rate,,35350.74,,,,,,,case rate,,29760.99,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,23001.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21851.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23001.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23001.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23001.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24151.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23001.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23001.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,23001.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,24151.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,23001.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23001.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23001.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32052.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32052.8,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23001.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,23001.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,35350.74,,facility
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,120,RC,,,,inpatient,,,,,41193.77,,,,,,,case rate,,36279.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36279.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,47306.45,,,,,,,case rate,,49896.02,,,,,,,case rate,,42006.33,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,36279.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,34465.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36279.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36279.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36279.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,38093.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,36279.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36279.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36279.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,38093.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,36279.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36279.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36279.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45241.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,45241.13,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,36279.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36279.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,49896.02,,facility
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,120,RC,,,,inpatient,,,,,34112.36,,,,,,,case rate,,25101.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25101.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,37326.19,,,,,,,case rate,,39369.44,,,,,,,case rate,,33144.24,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,25101.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23846.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25101.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25101.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25101.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26356.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25101.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25101.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25101.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,26356.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25101.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25101.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25101.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35696.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35696.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25101.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25101.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,39369.44,,facility
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,120,RC,,,,inpatient,,,,,13292.68,,,,,,,case rate,,10497.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10497.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14639.46,,,,,,,case rate,,15440.83,,,,,,,case rate,,12999.29,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10497.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9972.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10497.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10497.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10497.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11021.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10497.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10497.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10497.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11021.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10497.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10497.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10497.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14000.33,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14000.33,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10497.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10497.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15440.83,,facility
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,120,RC,,,,inpatient,,,,,18644.38,,,,,,,case rate,,14199.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14199.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19779.86,,,,,,,case rate,,20862.62,,,,,,,case rate,,17563.77,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14199.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13489.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14199.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14199.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14199.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14909.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14199.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14199.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14199.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14909.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14199.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14199.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14199.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18916.31,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18916.31,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14199.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14199.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20862.62,,facility
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,120,RC,,,,inpatient,,,,,15308.41,,,,,,,case rate,,11429.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11429.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16692.34,,,,,,,case rate,,17606.08,,,,,,,case rate,,14822.16,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11429.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10857.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11429.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11429.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11429.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12000.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11429.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11429.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11429.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12000.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11429.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11429.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11429.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15963.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15963.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11429.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11429.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17606.08,,facility
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,120,RC,,,,inpatient,,,,,37890.92,,,,,,,case rate,,27833.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27833.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,41885.22,,,,,,,case rate,,44178.03,,,,,,,case rate,,37192.48,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,27833.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26441.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27833.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27833.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27833.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29225.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27833.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27833.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,27833.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,29225.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,27833.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27833.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27833.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40056.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40056.58,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27833.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,27833.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,44178.03,,facility
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,120,RC,,,,inpatient,,,,,20020.31,,,,,,,case rate,,14373.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14373.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21295.7,,,,,,,case rate,,22461.44,,,,,,,case rate,,18909.78,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,14373.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13654.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14373.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14373.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14373.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15092.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14373.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14373.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14373.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15092.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14373.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14373.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14373.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20365.97,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20365.97,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14373.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14373.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,22461.44,,facility
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,120,RC,,,,inpatient,,,,,17134.46,,,,,,,case rate,,13219.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13219.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18738.64,,,,,,,case rate,,19764.4,,,,,,,case rate,,16639.2,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,13219.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12558.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13219.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13219.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13219.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13880.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13219.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13219.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13219.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,13880.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13219.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13219.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13219.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17920.55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17920.55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13219.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13219.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,19764.4,,facility
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,120,RC,,,,inpatient,,,,,46552.99,,,,,,,case rate,,35017.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35017.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,51921.31,,,,,,,case rate,,54763.5,,,,,,,case rate,,46104.15,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,35017.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33266.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35017.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35017.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35017.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36768.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35017.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35017.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35017.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36768.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35017.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35017.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35017.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49654.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49654.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35017.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35017.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,54763.5,,facility
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,120,RC,,,,inpatient,,,,,15344.54,,,,,,,case rate,,11089.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11089.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16301.47,,,,,,,case rate,,17193.82,,,,,,,case rate,,14475.09,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11089.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10535.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11089.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11089.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11089.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11644.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11089.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11089.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11089.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11644.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11089.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11089.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11089.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15589.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15589.78,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11089.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11089.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,17193.82,,facility
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,120,RC,,,,inpatient,,,,,12327.72,,,,,,,case rate,,9685.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9685.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12473.27,,,,,,,case rate,,13156.06,,,,,,,case rate,,11075.79,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,9685.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9201.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9685.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9685.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9685.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10169.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9685.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9685.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,9685.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10169.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9685.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9685.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9685.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11928.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11928.71,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9685.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9685.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,13156.06,,facility
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,120,RC,,,,inpatient,,,,,14387.11,,,,,,,case rate,,11071.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11071.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15808.78,,,,,,,case rate,,16674.16,,,,,,,case rate,,14037.6,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11071.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10517.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11071.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11071.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11071.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11625.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11071.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11071.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11071.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11625.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11071.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11071.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11071.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15118.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15118.6,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11071.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11071.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,16674.16,,facility
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,120,RC,,,,inpatient,,,,,15099.16,,,,,,,case rate,,10263.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10263.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13882.36,,,,,,,case rate,,14642.29,,,,,,,case rate,,12327.01,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10263.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9749.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10263.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10263.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10263.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10776.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10263.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10263.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10263.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10776.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10263.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10263.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10263.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13276.28,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13276.28,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10263.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10263.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15099.16,,facility
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,120,RC,,,,inpatient,,,,,13795.49,,,,,,,case rate,,10076.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10076.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14907.16,,,,,,,case rate,,15723.18,,,,,,,case rate,,13236.99,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10076.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9572.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10076.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10076.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10076.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10580.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10076.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10076.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10076.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10580.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10076.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10076.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10076.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14256.34,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14256.34,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10076.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10076.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,15723.18,,facility
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,120,RC,,,,inpatient,,,,,21054.52,,,,,,,case rate,,16662.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16662.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24711.69,,,,,,,case rate,,26064.41,,,,,,,case rate,,21943.04,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,16662.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15829.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16662.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16662.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16662.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17495.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16662.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16662.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16662.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,17495.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16662.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16662.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16662.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23632.82,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23632.82,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16662.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16662.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,26064.41,,facility
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,120,RC,,,,inpatient,,,,,18743.74,,,,,,,case rate,,15850.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15850.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19075.31,,,,,,,case rate,,20119.5,,,,,,,case rate,,16938.15,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,15850.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15058.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15850.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15850.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15850.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16643.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15850.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15850.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,15850.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,16643.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15850.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15850.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15850.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18242.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18242.52,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15850.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15850.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,20119.5,,facility
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,120,RC,,,,inpatient,,,,,13280.64,,,,,,,case rate,,10047.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10047.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14051.52,,,,,,,case rate,,14820.7,,,,,,,case rate,,12477.21,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,10047.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9544.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10047.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10047.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10047.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10549.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10047.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10047.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10047.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10549.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10047.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10047.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10047.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13438.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13438.05,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10047.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10047.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,14820.7,,facility
TRAUMATIC INJURY WITH MCC,913,MS-DRG,120,RC,,,,inpatient,,,,,24361.89,,,,,,,case rate,,18194.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18194.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24544.17,,,,,,,case rate,,25887.73,,,,,,,case rate,,21794.29,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,18194.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17285.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18194.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18194.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18194.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19104.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18194.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18194.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,18194.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,19104.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18194.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18194.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18194.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23472.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,23472.62,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18194.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18194.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,25887.73,,facility
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,120,RC,,,,inpatient,,,,,15847.35,,,,,,,case rate,,11835.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11835.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17166.96,,,,,,,case rate,,18106.69,,,,,,,case rate,,15243.61,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,11835.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11243.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11835.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11835.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11835.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12427.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11835.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11835.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,11835.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,12427.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11835.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11835.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11835.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16417.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16417.48,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11835.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11835.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1475,18106.69,,facility
ECHO GUIDE FOR BIOPSY,76942,CPT,402,RC,,,,outpatient,,,1424,1210.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,95.94,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,96.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,104.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,199.93,,,,,,,fee schedule,,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,33.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,29.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,146.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,124.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,37.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.99,3783,,facility
"STENT, NON-COA/NON-COV W/DEL",C1876,HCPCS,278,RC,,,,outpatient,,,2560,2176,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PRIVATE RM DIFF W/O PRIV BATH,00000011,CDM,111,RC,,,,inpatient,,,218,185.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,1475,5834,,facility
CT ORBIT/EAR/FOSSA W/DYE,70481,CPT,351,RC,,,,outpatient,,,2881,2448.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,596.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,642.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,206.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,904.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,766.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,3783,,facility
ASSAY BLD/SERUM CHOLESTEROL,82465,CPT,301,RC,,,,outpatient,,,390,331.5,,70,,7,7,7,26,percent of total billed charges,,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.1,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,10.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,10.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,4.35,4.35,4.35,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15.09,,,,,,,fee schedule,,,85,,11.32,11.32,15.09,22,percent of total billed charges,,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.35,,,,,,,fee schedule,,4.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,4.35,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,4.35,4.35,4.35,64,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,4.35,4.35,4.35,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,15.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.22,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.22,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.13,3783,,facility
IV PUMP (ABOTT/VALLEY LAB),05801005,CDM,270,RC,,,,outpatient,,,249,211.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
OFFICE O/P EST MOD 30 MIN,99214,CPT,510,RC,,,,outpatient,,,760,646,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,242.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,81.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,90.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,81.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,194.99,194.99,194.99,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,146.48,146.48,156.48,15,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,167.5,157.33,407.81,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,100.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,385.92,385.92,424.19,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,389.48,380.38,396.94,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,396.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,336.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,100.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,95.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,81.24,3783,,facility
OVA AND PARASITES SMEARS,87177,CPT,306,RC,,,,outpatient,,,259,220.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.49,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,20.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,20.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30.88,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.9,,,,,,,fee schedule,,8.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,8.9,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,31.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,9.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.46,3783,,facility
INITIAL TREATMENT OF BURN(S),16000,CPT,450,RC,,,,outpatient,,,459,390.15,826,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,236.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,877.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,236.76,1548,,facility
"IMMOBILIZER SHOULDER XL, WO",01404529,CDM,272,RC,,,,outpatient,,,88,74.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
RHEUMATOID FACTOR TEST QUAL,86430,CPT,302,RC,,,,outpatient,,,72,61.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.35,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,14.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19.67,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.14,,,,,,,fee schedule,,5.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,6.14,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,21.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,6.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.37,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.37,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.83,3783,,facility
CT GUIDE FOR TISSUE ABLATION,77013,CPT,350,RC,,,,outpatient,,,2299,1954.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,548.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,590.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2120.82,,,,,,,fee schedule,,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,170.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,190.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,170.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,210.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,831.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,704.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,210.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,200.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,170.23,3783,,facility
VEIN X-RAY KIDNEYS,75833,CPT,320,RC,,,,outpatient,,,12605,10714.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,316.77,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,10746.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,11570.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8735.5,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3333.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,3726.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,3333.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16276.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,13805.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4578.66,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4578.66,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,316.77,16276.8,,facility
DRUG SCREEN AMPHETAMINES 1/2,80324,CPT,301,RC,,,,outpatient,,,357,303.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,88.05,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,88.05,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,8745,7433.25,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
TUBING IRRIGATION LOW PROFILE,02712678,CDM,270,RC,,,,outpatient,,,429,364.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,6512,5535.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,1327,1127.95,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
OR TIME 1 MINUTE,01202070,CDM,360,RC,,,,outpatient,,,156,132.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3174,3783,,facility
OR TIME 90 MINUTES,01202090,CDM,360,RC,,,,outpatient,,,4986,4238.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3174,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1096,931.6,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1308,1111.8,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"CATH, THROMBECTOMY/EMBOLECT",C1757,HCPCS,278,RC,,,,outpatient,,,27186,23108.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
OR TIME 135 MINUTES,01202130,CDM,360,RC,,,,outpatient,,,5633,4788.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3174,3783,,facility
"PROS, URINARY SPH, IMP",C1815,HCPCS,278,RC,,,,outpatient,,,9971,8475.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,769,653.65,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"REP DEV, URINARY, W/SLING",C1771,HCPCS,278,RC,,,,outpatient,,,20414,17351.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1435,1219.75,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
10MM TENDON STRIPPER BLADE,02912088,CDM,270,RC,,,,outpatient,,,759,645.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SHORT OPPONENS SPLINT,04003151,CDM,270,RC,,,,outpatient,,,216,183.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
OFF/OP EST MAY X REQ PHY/QHP,99211,CPT,510,RC,,,,outpatient,,,459,390.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,21.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,7.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,45.45,20.2,245.2,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,30.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,9.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.32,3783,,facility
"CATHETER, GUIDING",C1887,HCPCS,278,RC,,,,outpatient,,,458,389.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PRIVATE ROOM W/O PRI BATH,00000009,CDM,120,RC,,,,inpatient,,,5201,4420.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,1475,5834,,facility
SEMI PRIVATE ROOM,00000003,CDM,121,RC,,,,inpatient,,,4986,4238.1,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,1475,5834,,facility
I&D ABSCESS SIMPLE/SINGLE,10060,CPT,510,RC,,,,outpatient,,,940,799,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,633.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,211.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,236.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,211.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1034.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,877.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,3783,,facility
AIRWAY INHALATION TREATMENT,94640,CPT,412,RC,,,,inpatient,,,774,657.9,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BODY FLUID CELL COUNT,89051,CPT,309,RC,,,,outpatient,,,276,234.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.35,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,12.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,12.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19.11,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.6,,,,,,,fee schedule,,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,5.6,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,19.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,5.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.72,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.72,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.32,3783,,facility
ASSAY OF PREALBUMIN,84134,CPT,301,RC,,,,outpatient,,,86,73.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59.16,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,33.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,33.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,50.61,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.59,,,,,,,fee schedule,,13.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,14.59,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,51.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,15.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.86,3783,,facility
RHEUMATOID FACTOR QUANT,86431,CPT,302,RC,,,,outpatient,,,98,83.3,,70,,8,8,8,12,percent of total billed charges,,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.35,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,13.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,13.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,6.83,6.83,6.83,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.25,5.25,5.25,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19.67,,,,,,,fee schedule,,,85,,19.67,19.67,19.67,1 through 10,percent of total billed charges,,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.67,,,,,,,fee schedule,,5.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,5.67,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.62,5.62,5.62,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,11.29,6.71,22.58,14,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,19.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,5.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.8,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.8,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.39,3783,,facility
VENT MGMT INPAT INIT DAY,94002,CPT,410,RC,,,,inpatient,,,2140,1819,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
POS AIRWAY PRESSURE CPAP,94660,CPT,419,RC,,,,inpatient,,,630,535.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
NEEDLE EMG 1 EXTREMITY,95860,CPT,922,RC,,,,outpatient,,,611,519.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,257.34,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,442.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,419.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,415.49,,,,,,,fee schedule,,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,157.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,685.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,581.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,218,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,140.48,3783,,facility
NDL EMG CRANIAL NRV MUSC BI,95868,CPT,922,RC,,,,outpatient,,,464,394.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,192.7,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,718.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,681.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,456.4,,,,,,,fee schedule,,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,254.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1113.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,944.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,218,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,192.7,3783,,facility
ELECTRIC STIMULATION THERAPY,97014,CPT,420,RC,,,,outpatient,,,271,230.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,207,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,,Payer contract is 268.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 268.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,207,,,,,,,case rate,,174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,175,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,148,,,,,,,case rate,,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,171,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,169,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,148,3783,,facility
PARAFFIN BATH THERAPY,97018,CPT,420,RC,,,,outpatient,,,271,230.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,207,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,19.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,207,,,,,,,case rate,,174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,30.43,,,,,,,fee schedule,,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,6.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,6.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,175,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,148,,,,,,,case rate,,7.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,171,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,169,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.05,3783,,facility
MR ANGIOGRAPH NECK W/O&W/DYE,70549,CPT,615,RC,,,,outpatient,,,6650,5652.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2127,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3610,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1187.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,1278.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3641,,,,,,,case rate,,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,368.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,411.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,368.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,455.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1798.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1525.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,455.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,588.99,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,588.99,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,368.36,3641,,facility
XRAY CONTROL CATHETER CHANGE,75984,CPT,320,RC,,,,outpatient,,,1027,872.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,237.9,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,115.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,124.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,358.53,,,,,,,fee schedule,,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,39.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,35.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,147.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,44.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.73,3783,,facility
"CATH, TRANSLUMIN NON-LASER",C1725,HCPCS,278,RC,,,,outpatient,,,1108,941.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ATOMIC ABSORPTION,82190,CPT,301,RC,,,,outpatient,,,137,116.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60.45,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,36.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,36.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51.73,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.9,,,,,,,fee schedule,,15.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,15.9,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,65.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,55.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,16.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19.08,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19.08,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.1,3783,,facility
HEMOGLOBIN PLASMA,83051,CPT,301,RC,,,,outpatient,,,155,131.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28.92,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,16.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,16.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25.37,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.31,,,,,,,fee schedule,,6.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,7.31,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,25.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,7.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.77,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.77,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.94,3783,,facility
HEPATITIS C REVRS TRNSCRPJ,87522,CPT,306,RC,,,,outpatient,,,1716,1458.6,,70,,71,71,71,1 through 10,percent of total billed charges,,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,173.49,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,99.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,99.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,38.67,38.67,38.67,24,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,43.52,43.52,43.52,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,148.59,,,,,,,fee schedule,,,85,,148.59,148.59,148.59,1 through 10,percent of total billed charges,,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.84,,,,,,,fee schedule,,40.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,42.84,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,48.34,24.17,53.55,13,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,19.34,19.34,38.67,18,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,20.7,20.7,41.39,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,38.67,38.67,38.67,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,44.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,96.39,96.39,96.39,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,19.34,19.34,19.34,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,177.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,83.14,83.14,92.11,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,150.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,44.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51.41,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,51.41,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40.7,3783,,facility
AUDIT/DAST 15-30 MIN,99408,CPT,914,RC,,,,outpatient,,,647,549.95,,70,,40,40,40,1 through 10,percent of total billed charges,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,164.13,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,164.13,3783,,professional
ADENOVIRUS ANTIBODY,86603,CPT,302,RC,,,,outpatient,,,121,102.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52.59,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,29.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,29.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44.65,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.87,,,,,,,fee schedule,,12.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,12.87,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,45.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,13.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.23,3783,,facility
FAMILY PSYTX W/O PT 50 MIN,90846,CPT,914,RC,,,,outpatient,,,921,782.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,315.17,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,317.39,,,,,,,fee schedule,,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,187.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,209.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,187.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,231.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,914.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,776.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,231.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,187.4,3783,,professional
ASSAY OF LITHIUM,80178,CPT,300,RC,,,,outpatient,,,124,105.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.28,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,15.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,15.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22.93,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.61,,,,,,,fee schedule,,6.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,6.61,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,23.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,6.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.93,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.93,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.28,3783,,facility
NOS EACH ORGANISM AG IA,87449,CPT,306,RC,,,,outpatient,,,271,230.35,,70,,13,13,13,1 through 10,percent of total billed charges,,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48.63,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,27.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,27.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41.59,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.98,,,,,,,fee schedule,,11.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,11.98,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,42.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,12.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.38,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.38,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.38,3783,,facility
HEPATITIS DELTA AGENT ANTBDY,86692,CPT,302,RC,,,,outpatient,,,194,164.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,69.66,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,39.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,39.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,59.54,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.16,,,,,,,fee schedule,,16.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,17.16,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,71.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,60.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,18.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.59,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20.59,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,17.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16.3,3783,,facility
RUBELLA ANTIBODY,86762,CPT,302,RC,,,,outpatient,,,163,138.55,,70,,20,20,20,1 through 10,percent of total billed charges,,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57.84,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,33.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,33.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,49.93,,,,,,,fee schedule,,,85,,49.93,49.93,49.93,1 through 10,percent of total billed charges,,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.39,,,,,,,fee schedule,,13.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,14.39,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,17.99,17.99,17.99,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,14.39,14.39,14.39,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,50.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,15.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.27,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17.27,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.67,3783,,facility
QUANTITATIVE ASSAY DRUG,80299,CPT,301,RC,,,,outpatient,,,301,255.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,68.34,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,43.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,43.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52.38,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.64,,,,,,,fee schedule,,17.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,18.64,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,77.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,65.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,19.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.37,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22.37,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,18.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.71,3783,,facility
CHEMILUMINESCENT ASSAY,82397,CPT,301,RC,,,,outpatient,,,340,289,,70,,15,15,15,1 through 10,percent of total billed charges,,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,56.52,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,32.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,32.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48.98,,,,,,,fee schedule,,,85,,48.98,48.98,48.98,1 through 10,percent of total billed charges,,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.12,,,,,,,fee schedule,,13.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,14.12,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,8.97,8.97,11.21,13,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,8.97,8.97,11.21,18,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,11.95,11.95,11.95,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,49.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,14.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16.94,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16.94,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.41,3783,,facility
COL CHROMOTOGRAPHY QUAL/QUAN,82542,CPT,301,RC,,,,outpatient,,,200,170,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,88.05,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,55.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,55.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,67.69,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.09,,,,,,,fee schedule,,22.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,24.09,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,15.14,15.14,15.14,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,15.14,15.14,15.14,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,99.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,84.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,25.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28.91,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28.91,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.89,3783,,facility
FLUORESCENT ANTIBODY SCREEN,86255,CPT,300,RC,,,,outpatient,,,175,148.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48.63,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,27.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,27.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41.81,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.05,,,,,,,fee schedule,,11.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,12.05,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,42.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,12.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.46,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.46,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.45,3783,,facility
ANTINUCLEAR ANTIBODIES,86038,CPT,302,RC,,,,outpatient,,,220,187,,70,,17,17,17,51,percent of total billed charges,,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48.63,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,28.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,28.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,6.83,6.83,6.83,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.25,5.25,5.25,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41.93,,,,,,,fee schedule,,,85,,41.93,31.44,41.93,1 through 10,percent of total billed charges,,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.09,,,,,,,fee schedule,,11.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,12.09,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.2,5.2,5.2,12,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.62,5.62,5.62,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,11.29,6.71,11.29,36,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,42.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,12.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.51,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.49,3783,,facility
CONVERSION EXT BIL DRG CATH,47535,CPT,361,RC,,,,outpatient,,,8375,7118.75,344,,,,,,,fee schedule,,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4060,,,,,,,fee schedule,,4060,,,,,,,fee schedule,,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4225.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4669.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18456.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,15655.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4669.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4447.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,344,18456.96,,facility
CLOT FACTOR VIII MULTIMETRIC,85247,CPT,305,RC,,,,outpatient,,,433,368.05,,70,,13,13,13,1 through 10,percent of total billed charges,,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,93.33,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,53.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,53.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,79.58,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.94,,,,,,,fee schedule,,21.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,22.94,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,11.77,11.77,11.77,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,95.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,80.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,24.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27.53,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27.53,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.79,3783,,facility
ORGANIC ACID SINGLE QUANT,83921,CPT,301,RC,,,,outpatient,,,383,325.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,77.55,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,49.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,49.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,59.6,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.21,,,,,,,fee schedule,,20.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,21.21,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,88.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,74.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,22.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25.45,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,25.45,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.15,3783,,facility
WIRE K BONE FIXATION 3X150MM,02714519,CDM,270,RC,,,,outpatient,,,88,74.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
KIT CENTRAL LINE PROTECTION,02713577,CDM,270,RC,,,,outpatient,,,160,136,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,1695,1440.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,856,727.6,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,2882,2449.7,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
PIN DISTRACTION TI YELLOW 14MM,02714196,CDM,270,RC,,,,outpatient,,,29,24.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
GUIDE WIRE 0.8X100MM TROCAR TI,02912183,CDM,270,RC,,,,outpatient,,,393,334.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,433,368.05,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,,,,outpatient,,,5746,4884.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,2371.2,750,2371.2,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
GUIDE WIRE,C1769,HCPCS,278,RC,,,,outpatient,,,224,190.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,5763,4898.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
BURR TOOL BALL DIAM 7.5CM 3MM,02713657,CDM,270,RC,,,,outpatient,,,607,515.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,5273,4482.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,2665,2265.25,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
ZIPWIRE STIFF .035 STR TIP BX,02713958,CDM,270,RC,,,,outpatient,,,156,132.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"IMPLANT/INSERT DEVICE, NOC",C1889,HCPCS,278,RC,,,,outpatient,,,5796,4926.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1588.8,1588.8,1588.8,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ENDOSCOPY RM TIME 195 MINUTES,00901012,CDM,360,RC,,,,outpatient,,,7102,6036.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3174,3783,,facility
CULTR BACTERIA EXCEPT BLOOD,87075,CPT,306,RC,,,,outpatient,,,241,204.85,,70,,14,14,14,1 through 10,percent of total billed charges,,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,38.13,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,21.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,21.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,12.31,12.31,12.31,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,9.47,9.47,9.47,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32.85,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.47,,,,,,,fee schedule,,9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,9.47,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,14.3,14.3,14.3,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,33.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,9.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.36,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11.36,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,9.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9,3783,,facility
PHARMACOLOGIC MGMT W/PSYTX,90863,CPT,944,RC,,,,outpatient,,,438,372.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,227,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,226,,,,,,,case rate,,227,,,,,,,case rate,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,226,3783,,facility
ECHO GUIDE VILLUS SAMPLING,76945,CPT,402,RC,,,,outpatient,,,894,759.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,229.98,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,98.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,106.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,350.13,,,,,,,fee schedule,,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,34.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,30.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,149.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,127,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,37.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.67,3783,,facility
ECHO EXAM OF FETAL HEART,76825,CPT,402,RC,,,,outpatient,,,3661,3111.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,709.77,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1859.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,2002.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1926,,,,,,,fee schedule,,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,576.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,644.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,576.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,712.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2816.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,2389.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,712.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,772.62,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,772.62,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,576.93,3783,,facility
WITHDRAWAL OF ARTERIAL BLOOD,36600,CPT,510,RC,,,,outpatient,,,423,359.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,419.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,157.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,685.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,581.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,3783,,facility
CRITICAL CARE ADDL 30 MIN,99292,CPT,450,RC,,,,outpatient,,,763,648.55,826,,,,,,,case rate,,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,109.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,120.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1021,,,,,,,case rate,,120.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,114.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,109.14,1548,,facility
ECHO TRANSESOPHAGEAL,93312,CPT,483,RC,,,,outpatient,,,3384,2876.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1050.03,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1819.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1724,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,2004.26,,,,,,,fee schedule,,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,576.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,644.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,576.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,712.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2816.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,2389.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,712.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,664,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,660,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,576.93,3783,,facility
APP MDLTY 1+IONTPHRSIS EA 15,97033,CPT,420,RC,,,,outpatient,,,271,230.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,207,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,58.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,207,,,,,,,case rate,,174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,68.56,,,,,,,fee schedule,,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,20.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,18.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,175,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,148,,,,,,,case rate,,22.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,171,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,169,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.51,3783,,facility
REPLICARE THIN 6 X 8,01404603,CDM,270,RC,,,,outpatient,,,35,29.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
US EXAM ABDO BACK WALL COMP,76770,CPT,402,RC,,,,outpatient,,,894,759.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,283.89,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,508.13,,,,,,,fee schedule,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
EXTREMITY STUDY,93971,CPT,921,RC,,,,outpatient,,,1112,945.2,,70,,140,140,140,1 through 10,percent of total billed charges,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,838.19,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,348.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,329.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,462.95,,,,,,,fee schedule,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,93.93,93.93,93.93,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1037,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
US EXAM PELVIC COMPLETE,76856,CPT,402,RC,,,,outpatient,,,979,832.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,279.96,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,499.2,,,,,,,fee schedule,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
SURGICAL SUPPLIES,A4649,HCPCS,272,RC,,,,outpatient,,,3440,2924,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
VOLUMEN ORAL,03506196,CDM,250,RC,,,,inpatient,,,111,94.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
51710069,051710069,CDM,272,RC,,,,outpatient,,,11,9.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ARTERY X-RAYS LUNG,75741,CPT,323,RC,,,,outpatient,,,12605,10714.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,295.74,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,10746.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,11570.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,8670.96,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3333.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,3726.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,3333.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16276.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,13805.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4578.66,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4578.66,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,295.74,16276.8,,facility
INSERT CATH PLEURA W/O IMAGE,32556,CPT,361,RC,,,,outpatient,,,5519,4691.15,790,,,,,,,fee schedule,,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3795,,,,,,,fee schedule,,3795,,,,,,,fee schedule,,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2264.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2502.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9891.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,8390.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2502.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5048,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5048,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,790,9891.94,,facility
REMOVE CVA LUMEN OBSTRUCT,75902,CPT,320,RC,,,,outpatient,,,2652,2254.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,245.79,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,56.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,61.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,246.02,,,,,,,fee schedule,,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,19.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,17.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,86.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,73.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,21.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.64,3783,,facility
FUNGUS NES ANTIBODY,86671,CPT,302,RC,,,,outpatient,,,197,167.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.95,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,28.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,28.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,42.52,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.25,,,,,,,fee schedule,,11.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,12.25,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,241.23,241.23,241.23,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,43.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,12.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.7,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.7,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.64,3783,,facility
CYTOMEG DNA AMP PROBE,87496,CPT,306,RC,,,,outpatient,,,555,471.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,141.96,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,81.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,81.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,121.76,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.09,,,,,,,fee schedule,,33.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,35.09,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,36.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,123.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,36.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.11,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42.11,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.34,3783,,facility
DRUG TEST PRSMV CHEM ANLYZR,80307,CPT,301,RC,,,,outpatient,,,390,331.5,,70,,79.81,79.81,79.81,11,percent of total billed charges,,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,235.26,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,144.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,144.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,9.85,9.85,9.85,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,27.88,25.35,28.37,55,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,201.84,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.14,,,,,,,fee schedule,,59.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,62.14,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,28.37,9.48,32.41,144,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,28.37,9.38,28.37,292,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,25.23,25.23,25.23,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,27.88,25.35,27.88,17,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,65.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,63.83,63.83,77.54,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,25.93,13.94,27.88,49,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,257.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,17.23,16.3,27.24,96,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,218.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,65.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,74.57,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,74.57,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,62.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59.03,3783,,facility
X-RAY XM SM INT 1CNTRST STD,74250,CPT,320,RC,,,,outpatient,,,827,702.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,297.06,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,596.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,642.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,465.34,,,,,,,fee schedule,,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,206.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,904.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,766.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,3783,,facility
ASSAY NEPHELOMETRY NOT SPEC,83883,CPT,301,RC,,,,outpatient,,,324,275.4,,70,,48,32,48,33,percent of total billed charges,,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.2,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,31.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,31.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47.18,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.6,,,,,,,fee schedule,,12.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,13.6,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,35.7,35.7,35.7,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,56.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,47.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,14.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16.32,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16.32,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.92,3783,,facility
ENTEROVIRUS ANTIBODY,86658,CPT,302,RC,,,,outpatient,,,124,105.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52.59,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,30.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,30.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,45.18,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.03,,,,,,,fee schedule,,12.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,13.03,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,54.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,45.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,13.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.64,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.64,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.38,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,5813,4941.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SUTURE SURGIPRO 5-0 18' CV-22,02912055,CDM,270,RC,,,,outpatient,,,440,374,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,1406,1195.1,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
IMPLANT BREAST SILICONE/EQ,L8600,HCPCS,278,RC,,,,outpatient,,,2708,2301.8,,70,,1754.4,1754.4,1754.4,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1890.4,750,3450.4,13,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2801.83,2801.83,2801.83,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
UNLISTED PX CLIN BRACHYTX,77799,CPT,333,RC,,,,outpatient,,,11909,10122.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19004,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,339.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,120.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,107.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,133.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,525.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,446.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,133.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1024,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.73,19004,,facility
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,,,,outpatient,,,2565,2180.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,559.68,559.68,559.68,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,1032.28,1032.28,1032.28,1 through 10,percent of total billed charges,,,40,,614.37,614.37,614.37,1 through 10,percent of total billed charges,,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,508.8,381.2,647.2,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,559.68,559.68,559.68,1 through 10,percent of total billed charges,,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",671.44,671.44,1342.88,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,508.8,508.8,1457.61,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
OR TIME 195 MINUTES,01202190,CDM,360,RC,,,,outpatient,,,7102,6036.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3174,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,488,414.8,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,6912,5875.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,458,389.3,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"CATHETER, GUIDING",C1887,HCPCS,278,RC,,,,outpatient,,,792,673.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
STIMULATOR NERVE 16HZ HEAD + N,04944301,CDM,278,RC,,,,outpatient,,,1563,1328.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1642,1395.7,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,535,454.75,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,2750,2337.5,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ROD SPINAL CURVED CT TI 3.5X80,04923356,CDM,278,RC,,,,outpatient,,,713,606.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,320,272,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"CATH, TRANSLUMIN, DRUG-COAT",C2623,HCPCS,278,RC,,,,outpatient,,,4081,3468.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"CATHETER, GUIDING",C1887,HCPCS,278,RC,,,,outpatient,,,377,320.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,3387,2878.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"PADDING WYTEX STERILE 3X4YD""",02713502,CDM,270,RC,,,,outpatient,,,9,7.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1232,1047.2,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SUTURE POLY TIES 3-0 USUL12,02713350,CDM,270,RC,,,,outpatient,,,17,14.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1063,903.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,408,346.8,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,326,277.1,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,5294,4499.9,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"HANDLE,LARYNGOSCOPE DISP STDDU",02712682,CDM,270,RC,,,,outpatient,,,25,21.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,2826,2402.1,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
"PROSTHESIS, PENILE, INFLATAB",C1813,HCPCS,278,RC,,,,outpatient,,,37273,31682.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,10167.52,10167.52,10167.52,1 through 10,percent of total billed charges,,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,17942.8,17942.8,17942.8,1 through 10,percent of total billed charges,,,40,,3567.2,3567.2,3567.2,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,8169.48,8169.48,8169.48,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,4594,3904.9,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,7294,6199.9,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
MATRIXX  CERVICAL 12DX14WX6H,04944078,CDM,278,RC,,,,outpatient,,,3413,2901.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ADAPTOR SWIVEL PORTEX 625191,02714148,CDM,270,RC,,,,outpatient,,,14,11.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
3.7 mm Tap,04920005,CDM,278,RC,,,,outpatient,,,1283,1090.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
K WIRE TROC PT 9X.062 1600-962,02912057,CDM,270,RC,,,,outpatient,,,49,41.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ROD THREADED EXTERNAL FIX 6X80,02714439,CDM,270,RC,,,,outpatient,,,193,164.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SUTURE ULTRABRAID #2 WHITE 38,02712776,CDM,270,RC,,,,outpatient,,,69,58.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,635,539.75,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
GUIDEWIRE NITINOL LENGTH 150CM,02713901,CDM,270,RC,,,,outpatient,,,74,62.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SABRE 2.0MM X 7 CM AR7200SR,02713889,CDM,270,RC,,,,outpatient,,,184,156.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
LEADS ECG SAFETY WHITE GREEN B,02714215,CDM,270,RC,,,,outpatient,,,697,592.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,422,358.7,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ADAPT/EXT, PACING/NEURO LEAD",C1883,HCPCS,278,RC,,,,outpatient,,,1948,1655.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,275.6,275.6,275.6,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,758,644.3,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PROSTHETIC IMPLANT NOS,L8699,HCPCS,278,RC,,,,outpatient,,,12943,11001.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",2608.32,2608.32,2608.32,36,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,,,,outpatient,,,9203,7822.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,8917.04,8917.04,8917.04,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,377,320.45,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
SCREW ZAVATION VAR SD 4.5X14MM,04944652,CDM,278,RC,,,,outpatient,,,1334,1133.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,12823,10899.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CATHETER 20FR 30CC FOLEY 3 WAY,02712611,CDM,270,RC,,,,outpatient,,,115,97.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
TRICUT BLADE 13CM,02712750,CDM,270,RC,,,,outpatient,,,1278,1086.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,300,255,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CATHETER GUIDE .018 90CM ANGLE,02713822,CDM,270,RC,,,,outpatient,,,604,513.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,461,391.85,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
SUTURE PS-2 3-0 UNDYED 27,02713468,CDM,270,RC,,,,outpatient,,,160,136,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,2389,2030.65,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,1435,1219.75,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,16995,14445.75,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SYRINGE 60CC LUER LOK,02713325,CDM,270,RC,,,,outpatient,,,3,2.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,279,237.15,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"CONN TISS, HUMAN(INC FASCIA)",C1762,HCPCS,278,RC,,,,outpatient,,,9068,7707.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
KIT FIBERTAK RC DISPOSABLES,02713064,CDM,270,RC,,,,outpatient,,,530,450.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,10852,9224.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CATHETER 24FR 30CC FOLEY 3 WAY,02712629,CDM,270,RC,,,,outpatient,,,115,97.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SYS ILIAC LIMB PMA 14 12X140MM,04922530,CDM,278,RC,,,,outpatient,,,17508,14881.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,6157,5233.45,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
IMPLANT BREAST SILICONE/EQ,L8600,HCPCS,278,RC,,,,outpatient,,,2303,1957.55,,70,,1754.4,1754.4,1754.4,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1890.4,750,3450.4,13,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2801.83,2801.83,2801.83,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,9785,8317.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,,,,outpatient,,,2482,2109.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,2371.2,750,2371.2,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"STENT, COATED/COV W/DEL SYS",C1874,HCPCS,278,RC,,,,outpatient,,,10705,9099.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,8917.04,8917.04,8917.04,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
INFUSE BONE GRAFT KIT SMALL,04921236,CDM,278,RC,,,,outpatient,,,12473,10602.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,,,,outpatient,,,4731,4021.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,2371.2,750,2371.2,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,2485,2112.25,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
GRAFT LORDOTIC HYDRATED 6MM,04922615,CDM,278,RC,,,,outpatient,,,5788,4919.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CATHETER 22FR 5CC FOLEY 11762,02912042,CDM,270,RC,,,,outpatient,,,32,27.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,850,722.5,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,422,358.7,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
ORTH/MATRX/BN FILL DRUG-ELUT,C1602,HCPCS,278,RC,,,,outpatient,,,20695,17590.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 85.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 105.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 105.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges.,,,,0,other,Payer contract is 100.00% of Medicare OPPS payment and based on reasonable cost. Payment determination is based on final charges. + No services performed during 15-month lookback period,3783,3783,,facility
MESH (IMPLANTABLE),C1781,HCPCS,278,RC,,,,outpatient,,,1811,1539.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,559.68,559.68,559.68,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,1032.28,1032.28,1032.28,1 through 10,percent of total billed charges,,,40,,614.37,614.37,614.37,1 through 10,percent of total billed charges,,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,508.8,381.2,647.2,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,559.68,559.68,559.68,1 through 10,percent of total billed charges,,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",671.44,671.44,1342.88,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,508.8,508.8,1457.61,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,11630,9885.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ZIPWIRE GW 035CM 260 STR 46-15,02712893,CDM,270,RC,,,,outpatient,,,117,99.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,277,235.45,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
SYRINGE BONE CEMENT MIXING DIS,02714524,CDM,270,RC,,,,outpatient,,,352,299.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,385,327.25,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1892,1608.2,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CANNULA ENDOSCOPIC 5MM DIA STA,02912011,CDM,272,RC,,,,outpatient,,,84,71.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,,,,outpatient,,,4398,3738.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,2371.2,750,2371.2,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CAGE SPINAL 12X14 6MM,04920972,CDM,278,RC,,,,outpatient,,,7958,6764.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,684,581.4,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"BB-TAK MTP, THREADED",02912190,CDM,270,RC,,,,outpatient,,,258,219.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ARTHROFLEX,Q4125,HCPCS,278,RC,,,,outpatient,,,11013,9361.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,107.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,132.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,126.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.54,3783,,facility
NAVI CROSS,02714217,CDM,270,RC,,,,outpatient,,,655,556.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SUTURE LOOPED WHT/BL COBRD #2,02712798,CDM,270,RC,,,,outpatient,,,2938,2497.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"PORT, INDWELLING, IMP",C1788,HCPCS,278,RC,,,,outpatient,,,1521,1292.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",424.6,424.6,424.6,18,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,6773,5757.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SUTURE 2-0 BIOSYN UNDYED CM830,02713346,CDM,270,RC,,,,outpatient,,,7,5.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1392,1183.2,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PASSPORT BUTTON CANNULA,02912269,CDM,270,RC,,,,outpatient,,,102,86.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
INSERT ONLAY TIBIAL SZ 5,102912111,CDM,270,RC,,,,outpatient,,,440,374,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,13047,11089.95,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SHUNT NEURO EXTERNAL 4X5MM,02712849,CDM,270,RC,,,,outpatient,,,5015,4262.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,334,283.9,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
NUT SPINAL RETAINER NON STERIL,02714434,CDM,270,RC,,,,outpatient,,,132,112.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,5943,5051.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,985,837.25,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
IMPLANT BREAST SILICONE/EQ,L8600,HCPCS,278,RC,,,,outpatient,,,2482,2109.7,,70,,1754.4,1754.4,1754.4,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1890.4,750,3450.4,13,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2801.83,2801.83,2801.83,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,6368,5412.8,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,485,412.25,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,14674,12472.9,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,922,783.7,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,10017,8514.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,1493,1269.05,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
DRILL CALIBRATED 4.0X280MM,02714347,CDM,270,RC,,,,outpatient,,,775,658.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,2438,2072.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1413,1201.05,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,7958,6764.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,8138,6917.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
GUIDE WIRE,C1769,HCPCS,278,RC,,,,outpatient,,,4476,3804.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,2494,2119.9,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,5775,4908.75,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"IMPLANT/INSERT DEVICE, NOC",C1889,HCPCS,278,RC,,,,outpatient,,,590,501.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1588.8,1588.8,1588.8,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,248,210.8,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PACK PLUNGER SHORT W/GW 10G,02714406,CDM,270,RC,,,,outpatient,,,592,503.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,9086,7723.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,501,425.85,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
IMPLANT BREAST SILICONE/EQ,L8600,HCPCS,278,RC,,,,outpatient,,,3584,3046.4,,70,,1754.4,1754.4,1754.4,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1890.4,750,3450.4,13,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2801.83,2801.83,2801.83,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1425,1211.25,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ACCUPASS STR 45 LT CURVE,02713709,CDM,270,RC,,,,outpatient,,,417,354.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,9664,8214.4,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,767,651.95,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,405,344.25,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
POST CHMBR INTRAOCULAR LENS,V2632,HCPCS,276,RC,,,,outpatient,,,522,443.7,,70,,165.2,164.8,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,273.88,273.88,273.88,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,181.6,155.2,1076.4,72,percent of total billed charges,,,85,,1076.4,1076.4,1076.4,1 through 10,percent of total billed charges,,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,1116.72,1116.72,1116.72,1 through 10,percent of total billed charges,,123.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,589.16,589.16,589.16,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,153.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2538,388,2691,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,145.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.87,3783,,facility
SURGIFOAM PORCINE POWDER 1GM,02912173,CDM,270,RC,,,,outpatient,,,187,158.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1599,1359.15,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
BALLOON UROMAX 15FX10CM,02713956,CDM,270,RC,,,,outpatient,,,677,575.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,13318,11320.3,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
BRA 4XLG SURGI ELIZABETH PINK,02713948,CDM,270,RC,,,,outpatient,,,89,75.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
TRAY FOLEY 16F SILICONE COATED,02713532,CDM,270,RC,,,,outpatient,,,20,17,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CATHETER PTA BALLOON 5X120MM,02714104,CDM,270,RC,,,,outpatient,,,2214,1881.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"CATH, TRANSLUMIN NON-LASER",C1725,HCPCS,278,RC,,,,outpatient,,,972,826.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
OSTEOTOME HRIS FLEX 12X93MM,02712791,CDM,270,RC,,,,outpatient,,,1679,1427.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SCREW LOW PROFILE HEX 6.5 X 30,04921230,CDM,278,RC,,,,outpatient,,,368,312.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,6223,5289.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ALYS NPGT W/O PRGRMG,95970,CPT,920,RC,,,,outpatient,,,507,430.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,315.84,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,442.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,419.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,80.45,,,,,,,fee schedule,,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,157.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,685.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,581.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,372,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,80.45,3783,,facility
"CATH, TRANS ATHEREC,ROTATION",C1724,HCPCS,278,RC,,,,outpatient,,,8669,7368.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
BIPOLAR ELECTRODE,02912036,CDM,272,RC,,,,outpatient,,,1543,1311.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1585,1347.25,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,751,638.35,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1223,1039.55,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CATHETER 22FR 5CC FOLEY 11762,02712632,CDM,270,RC,,,,outpatient,,,30,25.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,4010,3408.5,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
TEMP FIXATION PIN,02712715,CDM,270,RC,,,,outpatient,,,499,424.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1264,1074.4,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"CATH, TRANSLUMIN NON-LASER",C1725,HCPCS,278,RC,,,,outpatient,,,2188,1859.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1086,923.1,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"PROSTHESIS, BREAST, IMP",C1789,HCPCS,278,RC,,,,outpatient,,,2108,1791.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,2371.2,750,2371.2,1 through 10,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
GUIDE WIRE,C1769,HCPCS,278,RC,,,,outpatient,,,701,595.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
RP LOCLZJ TUM WHBDY 2+D IMG,78804,CPT,341,RC,,,,outpatient,,,5907,5020.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2648,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1848.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,1989.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,4254.31,,,,,,,fee schedule,,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,573.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,640.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,573.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,708.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2799.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,2374.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,708.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2089.5,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2089.5,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,573.29,4254.31,,facility
CATHETER DILUTION SOEHENORA,01404311,CDM,272,RC,,,,outpatient,,,233,198.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SHOE POST OP WOMEN SM 4-6,01404448,CDM,272,RC,,,,outpatient,,,73,62.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
INIT PM E/M NEW PAT 65+ YRS,99387,CPT,510,RC,,,,outpatient,,,741,629.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
OFFICE O/P NEW LOW 30 MIN,99203,CPT,510,RC,,,,outpatient,,,554,470.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,207.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,69.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,77.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,69.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,85.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,352.08,352.08,352.08,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,339.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,288.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,85.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,69.6,3783,,facility
ASSAY OTHER FLUID CHLORIDES,82438,CPT,301,RC,,,,outpatient,,,175,148.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19.71,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,11.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,11.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16.94,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5,,,,,,,fee schedule,,4.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,5,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,17.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,5.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.75,3783,,facility
TAP FOR DYNANITE PIP,02712295,CDM,270,RC,,,,outpatient,,,1712,1455.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
TRANSVAGINAL US OBSTETRIC,76817,CPT,402,RC,,,,outpatient,,,894,759.9,,70,,73,73,73,1 through 10,percent of total billed charges,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,216.87,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,513.53,,,,,,,fee schedule,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,80.85,80.85,80.85,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,151.06,151.06,151.06,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,343.89,147.62,343.89,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
X-RAY EXAM HIP UNI 2-3 VIEWS,73502,CPT,320,RC,,,,outpatient,,,510,433.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,126.18,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,296.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,318.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,249.11,,,,,,,fee schedule,,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,91.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,102.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,91.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,113.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,448.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,380.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,113.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,91.88,3783,,facility
BREAST PUMP KIT,01101028,CDM,270,RC,,,,outpatient,,,460,391,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PRIVATE RM DIFFERENTI.OBS/WO/S,00000043,CDM,112,RC,,,,inpatient,,,218,185.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,1475,5834,,facility
PRIVATE RM DIFFERENTIA.OBS/W/S,00000027,CDM,112,RC,,,,inpatient,,,218,185.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,1475,5834,,facility
DIALYSIS CIRCUIT EMBOLJ,36909,CPT,320,RC,,,,outpatient,,,915,777.75,8911,,,,,,,case rate,,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,567.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,610.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,733.8,,,,,,,fee schedule,,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,176,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,196.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,176,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,217.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,859.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,728.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,217.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,207.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,176,8911,,facility
N BLOCK INJ HYPOGAS PLXS,64517,CPT,361,RC,,,,outpatient,,,2827,2402.95,1648,,,,,,,fee schedule,,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3370,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1043.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1153.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4559.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,3867.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,1153.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1043.73,4559.44,,facility
BIOPSY ABDOMINAL MASS,49180,CPT,361,RC,,,,outpatient,,,3564,3029.4,1648,,,,,,,fee schedule,,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2086,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3795,,,,,,,fee schedule,,3795,,,,,,,fee schedule,,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1948.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2154.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8513.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,7221.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2154.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5048,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5048,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,8513.97,,facility
"INTRO/SHEATH, NON-LASER",C1894,HCPCS,278,RC,,,,outpatient,,,459,390.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
VASC EMBOLIZE/OCCLUDE ORGAN,37243,CPT,361,RC,,,,outpatient,,,42519,36141.15,1648,,,,,,,fee schedule,,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18082,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4335,,,,,,,fee schedule,,4335,,,,,,,fee schedule,,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13622.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15056.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59510.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,50476.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,15056.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11505,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11505,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14339.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,59510.25,,facility
"CATH, TRANSLUMIN NON-LASER",C1725,HCPCS,278,RC,,,,outpatient,,,739,628.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PROTHROMBIN TIME,85610,CPT,305,RC,,,,outpatient,,,117,99.45,,70,,6,6,6,120,percent of total billed charges,,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.78,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,9.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,9.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,5.14,5.14,5.14,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,3.95,3.95,8.89,16,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,8.89,8.89,8.89,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,13.63,,,,,,,fee schedule,,,85,,13.63,10.22,15.42,27,percent of total billed charges,,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.29,,,,,,,fee schedule,,4.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,4.29,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,111,4.89,111,25,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,111,3.91,111,100,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,4.23,4.23,4.23,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,8.89,8.89,8.89,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,3.95,3.95,3.95,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,5.05,5.05,8.49,15,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,15.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.15,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.15,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.08,3783,,facility
OFFICE O/P NEW LOW 30 MIN,99203,CPT,914,RC,,,,outpatient,,,554,470.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,619.55,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,103,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,103,,,,,,,case rate,,103,,,,,,,case rate,,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,69.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,77.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,69.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,190.99,34.04,197.08,34,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,85.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,64.25,64.25,64.25,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,339.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,288.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,85.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,81.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,69.6,3783,,professional
GUEST TRAYS,07804136,CDM,999,RC,,,,outpatient,,,23,19.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,3783,,facility
45 MINUTES IN PACU,01310045,CDM,710,RC,,,,outpatient,,,884,751.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
360 MINUTES IN PACU,01310360,CDM,710,RC,,,,outpatient,,,2837,2411.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
BAIR HUGGER WARMING BLANKET,01314018,CDM,270,RC,,,,outpatient,,,124,105.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
75 MINUTES IN PACU,01310075,CDM,710,RC,,,,outpatient,,,1123,954.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
120 MINUTES IN PACU,01310120,CDM,710,RC,,,,outpatient,,,1490,1266.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
IRRIG DRUG DELIVERY DEVICE,96523,CPT,335,RC,,,,outpatient,,,246,209.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,196.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1036,,,,,,,case rate,,872,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,69.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,62.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,76.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,300.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,255.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,76.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1117,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.29,3783,,facility
330 MINUTES IN PACU,01310330,CDM,710,RC,,,,outpatient,,,2705,2299.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
RECOVERY ROOM FEE,01310222,CDM,710,RC,,,,outpatient,,,1580,1343,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
300 MINUTES IN PACU,01310300,CDM,710,RC,,,,outpatient,,,2588,2199.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
270 MINUTES IN PACU,01310270,CDM,710,RC,,,,outpatient,,,2465,2095.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
EEG CEREBRAL DEATH ONLY,95824,CPT,740,RC,,,,outpatient,,,1196,1016.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,418.48,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1242.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1177.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,421.89,,,,,,,fee schedule,,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,394,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,440.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,394,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,486.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1900.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1613.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,486.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,938,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,935,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,394,3783,,facility
UPR/LXTR ART STDY 3+ LVLS,93923,CPT,921,RC,,,,outpatient,,,1112,945.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,919.33,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,718.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,681.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,473.4,,,,,,,fee schedule,,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,254.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1113.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,944.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1037,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,227.98,3783,,facility
EEG W/O VID 2-12 HR UNMNTR,95705,CPT,740,RC,,,,outpatient,,,3642,3095.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,718.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,681.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,254.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1099.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,933.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,938,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,935,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,227.98,3783,,facility
VEEG EA 12-26 HR UNMNTR,95714,CPT,740,RC,,,,outpatient,,,1919,1631.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1242.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1177.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,394,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,440.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,394,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,486.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1900.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1613.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,486.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,938,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,935,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,394,3783,,facility
EEG PHY/QHP>84 HR W/VEEG,95726,CPT,740,RC,,,,outpatient,,,1586,1348.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1052.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,997.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,333.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,373.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,333.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,412.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1610.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1366.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,412.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,938,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,935,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,392.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,333.86,3783,,facility
EEG AWAKE AND DROWSY,95816,CPT,740,RC,,,,outpatient,,,1005,854.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,851.01,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,718.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,681.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1005,,,,,,,fee schedule,,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,254.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,44.19,44.19,44.19,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,35.35,35.35,44.19,29,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,35.35,35.35,35.35,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1099.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,933.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,938,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,935,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,227.98,3783,,facility
EEG PHY/QHP>36<60 HR W/O VID,95721,CPT,740,RC,,,,outpatient,,,809,687.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,539.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,511.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,171.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,191.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,171.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,211.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,825.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,700.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,211.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,938,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,935,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,171.13,3783,,facility
EEG PHY/QHP>36<60 HR W/VEEG,95722,CPT,740,RC,,,,outpatient,,,985,837.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,652.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,618.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,206.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,231.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,206.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,255.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,998.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,847.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,255.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,938,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,935,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,243.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,206.91,3783,,facility
EEG WO VID EA 12-26HR UNMNTR,95708,CPT,740,RC,,,,outpatient,,,1919,1631.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1242.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1177.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,394,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,440.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,394,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,486.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1900.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1613.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,486.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,938,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,935,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,394,3783,,facility
PROSTATE CA SCREENING; DRE,G0102,HCPCS,510,RC,,,,outpatient,,,647,549.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,21.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,7.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,30.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,9.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.32,3783,,facility
PREV MED CNSL INDIV APPRX 15,99401,CPT,510,RC,,,,outpatient,,,281,238.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
OFFICE O/P EST LOW 20 MIN,99213,CPT,510,RC,,,,outpatient,,,598,508.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,164.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,61.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,55.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,235.66,235.66,291.82,12,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,188.53,143.47,233.46,14,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,184.78,176.06,416.9,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,68.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,328.75,328.75,388.42,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,389.48,146.98,407.52,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,269.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,347.96,347.96,387.69,22,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,228.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,68.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.16,3783,,facility
PREV MED CNSL INDIV APPRX 30,99402,CPT,510,RC,,,,outpatient,,,441,374.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
SARS-COV-2 COVID-19 ANTIBODY,86769,CPT,300,RC,,,,outpatient,,,165,140.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,97.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,97.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.13,,,,,,,fee schedule,,40.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,42.13,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,148.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,44.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,50.56,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,50.56,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,42.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40.02,3783,,facility
ACUPUNCTURE REHAB VISIT,03299343,CDM,510,RC,,,,outpatient,,,95,80.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,3783,,facility
DEXT5% SODCHL 9% 500ML/OTH,01507128,CDM,260,RC,,,,outpatient,,,124,105.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,3783,,facility
EXTRACTOR BALLOON STONE 6.8,01404408,CDM,272,RC,,,,outpatient,,,522,443.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
BRACES/SPECIALTY DEVICES,01404234,CDM,272,RC,,,,outpatient,,,827,702.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SPHINCTERTOME #4344,01404431,CDM,272,RC,,,,outpatient,,,1283,1090.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
TUBE GASTROSTOMY REPLACE 20,01517423,CDM,260,RC,,,,outpatient,,,218,185.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,3783,,facility
REPLICARE 8 X 8,01404549,CDM,270,RC,,,,outpatient,,,125,106.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PACK COLD,01404387,CDM,272,RC,,,,outpatient,,,32,27.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CATHETER ESOPHALEAL BALLOON,01404443,CDM,272,RC,,,,outpatient,,,1048,890.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CARDIAC CATH SUPPLIES,01403005,CDM,272,RC,,,,outpatient,,,402,341.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SCD SLEEVE LARGE 5480,01404243,CDM,272,RC,,,,outpatient,,,718,610.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JACKSON TRACH TUBE,01404222,CDM,272,RC,,,,outpatient,,,178,151.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CATH KIT SUCTION 12FR,01404323,CDM,272,RC,,,,outpatient,,,28,23.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
BANDAGE KERLIX LITE 3 NS,01404389,CDM,272,RC,,,,outpatient,,,52,44.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
DEXT 5% SODCHL 9% 1000ML/OT,01507129,CDM,258,RC,,,,inpatient,,,124,105.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
RIGI FLEX TTS 2.8MM X180CM,01404300,CDM,272,RC,,,,outpatient,,,958,814.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
BLOOD Y SET SL,01517429,CDM,260,RC,,,,outpatient,,,73,62.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,3783,,facility
SOD CHL 9% 500 ML/THERAPY,01507132,CDM,260,RC,,,,outpatient,,,124,105.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,3783,,facility
DEXT 5% SODCHL 1/4 1000ML/THER,01507123,CDM,260,RC,,,,outpatient,,,124,105.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,3783,,facility
"RET DEV, INSERTABLE",C1773,HCPCS,278,RC,,,,outpatient,,,1724,1465.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
DEXT 5% INJ LC 1000ML/THER,01517383,CDM,260,RC,,,,outpatient,,,124,105.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,3783,,facility
IMMOBILIZER SHOULDER SM MEN,01404528,CDM,272,RC,,,,outpatient,,,88,74.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
Manifold Kit Custom Tray/Pack,057100065,CDM,272,RC,,,,outpatient,,,77,65.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SPLINT CLAVICLE SMALL,01404502,CDM,272,RC,,,,outpatient,,,53,45.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CT ANGIO LWR EXTR W/O&W/DYE,73706,CPT,350,RC,,,,outpatient,,,3234,2748.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,596.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,642.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,206.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,904.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,766.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,3783,,facility
CT ANGIOGRAPHY HEAD,70496,CPT,351,RC,,,,outpatient,,,3234,2748.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,596.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,642.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,206.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,904.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,766.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,3783,,facility
CTA ABDOMEN W/CONTRAST,74175,CPT,352,RC,,,,outpatient,,,3496,2971.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,596.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,642.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,206.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,904.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,766.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,3783,,facility
CT UPPR EXTREMITY W/O&W/DYE,73202,CPT,352,RC,,,,outpatient,,,3054,2595.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,596.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,642.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,206.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,904.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,766.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,3783,,facility
CT ORBIT/EAR/FOSSA W/O DYE,70480,CPT,351,RC,,,,outpatient,,,2881,2448.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
CT BONE DENSITY AXIAL,77078,CPT,359,RC,,,,outpatient,,,1339,1138.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,296.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,318.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,91.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,102.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,91.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,113.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,448.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,380.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,113.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,91.88,3783,,facility
CT ABDOMEN W/CONTRAST,74160,CPT,352,RC,,,,outpatient,,,1196,1016.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,596.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,642.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,206.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,904.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,766.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,3783,,facility
CT MAXILLOFACIAL W/O & W/DYE,70488,CPT,351,RC,,,,outpatient,,,3203,2722.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,596.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,642.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,206.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,904.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,766.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,3783,,facility
CT THORAX DX C-,71250,CPT,350,RC,,,,outpatient,,,2881,2448.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
CT LOWER EXTREMITY W/DYE,73701,CPT,352,RC,,,,outpatient,,,2881,2448.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,596.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,642.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,206.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,904.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,766.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,3783,,facility
CTA ABD&PLVS W/CONTRAST,74174,CPT,350,RC,,,,outpatient,,,2149,1826.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1187.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,1278.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,368.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,411.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,368.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,455.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1798.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1525.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,455.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,588.99,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,588.99,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,433.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,368.36,3783,,facility
CT CHEST SPINE W/O & W/DYE,72130,CPT,352,RC,,,,outpatient,,,2881,2448.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,596.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,642.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,206.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,904.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,766.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,3783,,facility
CT LUMBAR SPINE W/O & W/DYE,72133,CPT,352,RC,,,,outpatient,,,3486,2963.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,596.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,642.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,206.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,904.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,766.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,3783,,facility
3D RENDER W/INTRP POSTPROCES,76376,CPT,359,RC,,,,outpatient,,,1290,1096.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,28.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,79.05,,,,,,,fee schedule,,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,9.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,8.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,43.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,11.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.93,3783,,facility
CT ORBIT/EAR/FOSSA W/O&W/DYE,70482,CPT,351,RC,,,,outpatient,,,3029,2574.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,596.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,642.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,206.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,904.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,766.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,3783,,facility
CT PELVIS W/O DYE,72192,CPT,352,RC,,,,outpatient,,,2881,2448.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
CT ANGIO ABDOMINAL ARTERIES,75635,CPT,352,RC,,,,outpatient,,,4569,3883.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,596.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,642.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,206.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,904.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,766.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,3783,,facility
CT LWR EXTREMITY W/O&W/DYE,73702,CPT,352,RC,,,,outpatient,,,3054,2595.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1967,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,596.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,642.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1640,,,,,,,case rate,,1640,,,,,,,case rate,,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,206.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,185.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,904.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,766.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,228.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,285.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,217.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,185.2,3783,,facility
TEMPORARY PM INSERT SUPPLIES,05701008,CDM,272,RC,,,,outpatient,,,630,535.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
RADIAL ARTERY CATH SUPPLIES,05710000,CDM,272,RC,,,,outpatient,,,319,271.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
RADIAL ARTERY CATH SUPPLIES,05701000,CDM,272,RC,,,,outpatient,,,319,271.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
INTENSIVE CARE UNIT,00000004,CDM,200,RC,,,,inpatient,,,5423,4609.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,4221,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,4187,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,3366,,,,,,,per diem,,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,7293,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,7293,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,1475,7293,,facility
IV PUMP,05701017,CDM,272,RC,,,,outpatient,,,124,105.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SWAN GANZCATH SUPPLIES,05701006,CDM,272,RC,,,,outpatient,,,1048,890.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
JOINT DEVICE (IMPLANTABLE),C1776,HCPCS,278,RC,,,,outpatient,,,3801,3230.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4788.99,4788.99,8408.4,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,6372.4,6302.4,13553.2,84,percent of total billed charges,,,40,,7302.8,7302.8,7302.8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,6875.88,6875.88,6875.88,1 through 10,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",7578.12,7578.12,7578.12,1 through 10,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,5119.08,5119.08,5119.08,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"ANCHOR/SCREW BN/BN,TIS/BN",C1713,HCPCS,278,RC,,,,outpatient,,,1719,1461.15,,70,,2294.4,519.2,2294.4,17,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,1410.2,254.76,2242.55,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1323.2,505.2,5152.8,173,percent of total billed charges,,,40,,3331.2,247.5,3365.12,24,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,4869.04,4869.04,4869.04,170,percent of total billed charges,,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",3181.2,770,7106.44,253,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2027.68,2027.68,2214.8,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CANNULA NASAL SALTER SOFT,02713556,CDM,270,RC,,,,outpatient,,,3,2.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
IMPLANT BREAST SILICONE/EQ,L8600,HCPCS,278,RC,,,,outpatient,,,2971,2525.35,,70,,1754.4,1754.4,1754.4,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,1890.4,750,3450.4,13,percent of total billed charges,,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,2801.83,2801.83,2801.83,1 through 10,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
REFLEXOLOGY 30 MIN.,03299347,CDM,510,RC,,,,outpatient,,,82,69.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,3783,,facility
WHOLE BLOOD FOR TRANSFUSION,P9010,HCPCS,390,RC,,,,outpatient,,,844,717.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,160.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,179.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,160.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,198.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,37,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,198.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1314,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1538,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,160.57,3783,,facility
"BLOOD, L/R, FROZ/DEGLY/WASH",P9054,HCPCS,390,RC,,,,outpatient,,,2025,1721.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,224.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,250.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,224.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,277.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,37,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,277.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1314,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1538,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,263.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,224.31,3783,,facility
WHOLE BLOOD FOR TRANSFUSION,P9010,HCPCS,390,RC,,,,outpatient,,,1655,1406.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,160.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,179.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,160.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,198.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,37,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,198.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1314,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1538,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,188.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,160.57,3783,,facility
APPLY SHORT LEG CAST,29405,CPT,450,RC,,,,outpatient,,,900,765,826,,,,,,,case rate,,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,330.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,364.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1222.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,364.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,347.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,330.06,1548,,facility
GIARDIA LAMBLIA ANTIBODY,86674,CPT,302,RC,,,,outpatient,,,121,102.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59.16,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,34.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,34.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,51.06,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.72,,,,,,,fee schedule,,13.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,14.72,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,61.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,51.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,15.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.66,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17.66,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.98,3783,,facility
EXPL PENTRG WOUND EXTREMITY,20103,CPT,450,RC,,,,outpatient,,,3626,3082.1,826,,,,,,,case rate,,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1948.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2154.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,7221.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2154.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,7221.49,,facility
CLOSTRIDIUM AG IA,87324,CPT,306,RC,,,,outpatient,,,70,59.5,,70,,13,13,13,1 through 10,percent of total billed charges,,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48.63,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,27.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,27.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41.59,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.98,,,,,,,fee schedule,,11.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,11.98,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,42.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,12.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.38,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.38,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.38,3783,,facility
DELTA ROLL CAST PAD. 6X4YDS.,03804138,CDM,700,RC,,,,outpatient,,,70,59.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ELASTIC LACES,04003131,CDM,270,RC,,,,outpatient,,,47,39.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
LONG LEG CAST FIBERGLASS,03805010,CDM,700,RC,,,,outpatient,,,2200,1870,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
DELTA LITE CAST.TAPE 5X4YDS.,03804142,CDM,700,RC,,,,outpatient,,,170,144.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
DELTA ROLL CAST PAD.4X4YDS.,03804137,CDM,700,RC,,,,outpatient,,,67,56.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
UNILATERAL HIP SPICA CAST PLAS,03805015,CDM,700,RC,,,,outpatient,,,556,472.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
SOFT COLLAR,02803235,CDM,271,RC,,,,outpatient,,,155,131.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PT EVAL HIGH COMPLEX 45 MIN,97163,CPT,424,RC,,,,outpatient,,,658,559.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,207,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,295.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,207,,,,,,,case rate,,174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,274.99,,,,,,,fee schedule,,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,93.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,104.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,93.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,115.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,175,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,148,,,,,,,case rate,,115.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,171,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,169,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,110.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,93.63,3783,,facility
HOLOGIC EVIVA STX NEEDLE GUIDE,05710091,CDM,272,RC,,,,outpatient,,,52,44.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
DRUG SCREENING BARBITURATES,80345,CPT,300,RC,,,,outpatient,,,310,263.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,88.05,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,88.05,3783,,facility
RIVERVIEW SUITE RM DIFFERENTL,00000018,CDM,141,RC,,,,inpatient,,,612,520.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,1475,5834,,facility
PRIVATE ROOM,00000020,CDM,111,RC,,,,inpatient,,,5423,4609.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,4612,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,1475,5834,,facility
UNLISTED MAXLFCL PROSTH PX,21089,CPT,450,RC,,,,outpatient,,,752,639.2,826,,,,,,,case rate,,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,279.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,308.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1035.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,308.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,279.5,1548,,facility
US EXAM CHEST,76604,CPT,402,RC,,,,outpatient,,,452,384.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,186.63,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,452,,,,,,,fee schedule,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,25.25,25.25,25.25,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,56.81,56.81,56.81,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,30.9,30.9,30.9,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
RPR F/E/E/N/L/M 2.5 CM/<,12011,CPT,450,RC,,,,outpatient,,,777,660.45,826,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,236.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,596,596,596,12,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,877.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,236.76,1548,,facility
SIGN LANG/INTERPRETER/15 MIN,T1013,HCPCS,450,RC,,,,outpatient,,,59,50.15,826,,,,,,,case rate,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,813,1548,,facility
UNLISTED PX TRACHEA BRONCHI,31899,CPT,361,RC,,,,outpatient,,,549,466.65,1648,,,,,,,fee schedule,,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,235.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,260.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1028.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,872.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,260.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,247.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,235.55,3783,,facility
PRCRD DRG 6YR+ W/O CGEN CAR,33017,CPT,450,RC,,,,outpatient,,,1074,912.9,826,,,,,,,case rate,,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8512,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,246.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,271.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,911.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,271.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,258.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,246.03,8512,,facility
UNLISTED PX NERVOUS SYSTEM,64999,CPT,450,RC,,,,outpatient,,,857,728.45,826,,,,,,,case rate,,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,362.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,400.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1342.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,400.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,362.22,1548,,facility
EMERGENCY DEPT VISIT LOW MDM,99283,CPT,450,RC,,,,outpatient,,,1472,1251.2,826,,,,,,,case rate,,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,31.73,31.73,31.73,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,187.94,165.15,225.8,32,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,362.86,330.84,433.08,106,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,322.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,175.09,153.73,210.5,587,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,196.78,176.32,297.34,73,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,175.68,151.25,225.8,558,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,206.3,168.5,512.02,21,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,356.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,386.93,365.33,485.6,11,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,455.01,455.01,455.01,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,212.02,165.15,463.88,83,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,430.02,374.12,448.21,18,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,1021,,,,,,,case rate,,356.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1572,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1572,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,339.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,322.13,1572,,facility
CMPLX RPR F/C/C/M/N/AX/G/H/F,13133,CPT,450,RC,,,,outpatient,,,656,557.6,826,,,,,,,case rate,,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,112.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,124.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,417.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,124.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,118.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,112.68,1548,,facility
US EXAM ABDO BACK WALL LIM,76775,CPT,402,RC,,,,outpatient,,,896,761.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,111.72,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,484.64,,,,,,,fee schedule,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
APPLICATION OF FINGER SPLINT,29131,CPT,450,RC,,,,outpatient,,,241,204.85,826,,,,,,,case rate,,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,69.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,76.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,257.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,76.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,69.62,1548,,facility
RPR F/E/E/N/L/M 5.1-7.5 CM,12014,CPT,450,RC,,,,outpatient,,,401,340.85,826,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,236.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,877.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,236.76,1548,,facility
CBT EACH ADDL HOUR,94645,CPT,410,RC,,,,inpatient,,,269,228.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PRICVATE RM DIFFERENTIAL TELEM,00000051,CDM,214,RC,,,,inpatient,,,218,185.3,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,4221,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,4187,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,3366,,,,,,,per diem,,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,7293,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,7293,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,1475,7293,,facility
AIRWAY INHALATION TREATMENT,94640,CPT,410,RC,,,,inpatient,,,761,646.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
RP LOCLZJ TUM SPECT 1 AREA,78803,CPT,341,RC,,,,outpatient,,,6480,5508,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2648,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1848.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,1989.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1706.29,,,,,,,fee schedule,,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,573.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,640.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,573.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,708.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2799.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,2374.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,708.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2089.5,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2089.5,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,573.29,3783,,facility
CHEST WALL MANIPULATION,94667,CPT,460,RC,,,,outpatient,,,312,265.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,442.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,419.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,94.56,,,,,,,fee schedule,,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,157.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,685.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,581.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,94.56,3783,,facility
CHEST WALL MANIPULATION,94667,CPT,410,RC,,,,inpatient,,,312,265.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
HT MUSCLE IMAGE SPECT MULT,78452,CPT,341,RC,,,,outpatient,,,4877,4145.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2648,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,4406.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,4744.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,4342.88,,,,,,,fee schedule,,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1366.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,1527.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,1366.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1688.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6673.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,5660.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,1688.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2089.5,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2089.5,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1608.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1366.94,6673.91,,facility
BRAIN IMAGE W/FLOW 4 + VIEWS,78606,CPT,341,RC,,,,outpatient,,,3631,3086.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2648,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1848.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,1989.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1641.15,,,,,,,fee schedule,,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,573.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,640.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,573.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,708.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2799.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,2374.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,708.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,783.04,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,783.04,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,674.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,573.29,3783,,facility
MUSC TEST DONE W/N TEST COMP,95886,CPT,922,RC,,,,outpatient,,,170,144.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,137.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,129.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,170,,,,,,,fee schedule,,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,43.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,48.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,43.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,53.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,212.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,180.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,53.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,218,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,43.49,3783,,facility
HOME SLEEP TEST/TYPE 4 PORTA,G0400,HCPCS,929,RC,,,,outpatient,,,947,804.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5152,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,718.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,681.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,287.04,,,,,,,fee schedule,,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,254.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1113.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,944.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,543,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,540,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,227.98,5152,,facility
EVALUATE PT USE OF INHALER,94664,CPT,410,RC,,,,inpatient,,,585,497.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
CO/MEMBANE DIFFUSE CAPACITY,94729,CPT,460,RC,,,,outpatient,,,541,459.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,26.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,187.71,,,,,,,fee schedule,,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,10.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,8.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,43.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,37.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,11.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.97,3783,,facility
PULMONARY STRESS TESTING,94618,CPT,460,RC,,,,outpatient,,,521,442.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,396.8,396.8,396.8,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,442.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,419.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,113.13,,,,,,,fee schedule,,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,157.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,685.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,581.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,113.13,3783,,facility
RVSC EVSC FPVT ST ATHRC SF 1,37275,CPT,361,RC,,,,outpatient,,,75792,64423.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21632.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23909.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,94499.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,80153.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,23909.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3174,94499.48,,facility
INTERPATION OF XRAY,08030027,CDM,940,RC,,,,outpatient,,,115,97.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1037,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1037,3783,,facility
DYNAMIC COCK-UP SPLINT,04003158,CDM,270,RC,,,,outpatient,,,522,443.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
LONG SPONGE,04003125,CDM,270,RC,,,,outpatient,,,58,49.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
HAND HELPER,04003135,CDM,270,RC,,,,outpatient,,,136,115.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
VENT MGMT INPAT SUBQ DAY,94003,CPT,412,RC,,,,inpatient,,,1253,1065.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
MV PRE COUNSELING W/O TESTING,06101026,CDM,510,RC,,,,outpatient,,,549,466.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,3783,,facility
INTERMEDIATE VISUAL FIELD XM,92082,CPT,920,RC,,,,outpatient,,,449,381.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,263.97,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,196.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,186.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,162.28,,,,,,,fee schedule,,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,69.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,62.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,76.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,304.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,257.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,76.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,374,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,372,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.29,3783,,facility
OFFICE O/P NEW SF 15 MIN,99202,CPT,510,RC,,,,outpatient,,,517,439.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,118.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,44.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,39.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,151.4,151.4,151.41,11,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,193.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,325.51,325.51,325.51,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,163.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,48.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.55,3783,,facility
OFFICE O/P EST SF 10 MIN,99212,CPT,510,RC,,,,outpatient,,,511,434.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,89.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,180.32,180.32,180.32,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,33.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,30.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,189.26,166.54,208.18,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,164.48,140.83,172.63,73,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,176.06,176.06,176.06,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,374.72,374.72,374.72,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,167.05,151.4,416.32,16,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,146.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,325.51,302.78,325.51,15,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,124.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,37.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.05,3783,,facility
PHYS/QHP OP CAR RHAB WO ECG,93797,CPT,943,RC,,,,outpatient,,,521,442.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,115.61,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,28.44,,,,,,,fee schedule,,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,136.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,152.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,136.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,168.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,664.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,563.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,168.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,730,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,728,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,160.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28.44,3783,,facility
ENDOSCOPY RM TIME 210 MINUTES,00901013,CDM,360,RC,,,,outpatient,,,7714,6556.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3174,3783,,facility
DETOX PRIVATE ROOM W/SEMI RATE,00000031,CDM,116,RC,,,,inpatient,,,2389,2030.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5381,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1475,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1475,,,,,,,per diem,,1475,,,,,,,per diem,,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,2037,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,2037,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,1475,5381,,facility
CORDIS INFINITI 5Fr JL 6.0,02907379,CDM,278,RC,,,,outpatient,,,62,52.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
INTERNAL FETAL MONITOR PROBE,01101016,CDM,270,RC,,,,outpatient,,,249,211.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
INTRAUTERINE PRESSURE CATHETER,01101020,CDM,270,RC,,,,outpatient,,,383,325.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
FETAL NON-STRESS TEST,59025,CPT,720,RC,,,,inpatient,,,656,557.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,202.35,202.35,202.35,21,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,202.35,202.35,202.35,1 through 10,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,202.35,202.35,202.35,194,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,287.72,287.72,327.65,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,262.12,15.15,287.72,35,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,262.12,262.12,287.72,1 through 10,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,647.37,647.37,647.37,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,262.12,140.82,287.72,11,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,563.56,275.24,563.56,18,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
LABOR SERVICE,01101001,CDM,721,RC,,,,inpatient,,,3750,3187.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
C-SECTION OR TIME,01101002,CDM,722,RC,,,,inpatient,,,5276,4484.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
INFANT RESUSCITATION EQUIP.,01101022,CDM,270,RC,,,,outpatient,,,1034,878.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
RECOVERY CARE 2hrs,01101019,CDM,729,RC,,,,inpatient,,,1724,1465.4,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BREATH RECORDING INFANT,94772,CPT,460,RC,,,,outpatient,,,3117,2649.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1242.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1177.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,394,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,440.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,394,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,486.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1923.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1631.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,486.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,394,3783,,facility
NURSERY,00000013,CDM,171,RC,,,,inpatient,,,5423,4609.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,1960,,,,,,,per diem,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,2474,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,3414,,,,,,,per diem,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3272,,,,,,,per diem,,2310,,,,,,,per diem,,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,3763,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,3763,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,1960,3763,,facility
IMMUNIZATION ADMIN,90471,CPT,771,RC,,,,outpatient,,,231,196.35,,70,,10,10,10,1 through 10,percent of total billed charges,,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,94.46,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,55.77,55.77,55.77,1 through 10,percent of total billed charges,,227.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,17.85,17.85,17.85,11,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,207,187,207,1 through 10,percent of total billed charges,,68.85,,,,,,,fee schedule,,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,76.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,84.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,76.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,16.7,16.7,220,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,220,220,220,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,33.26,33.26,33.26,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,14.78,14.78,14.78,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,371.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,63.55,63.55,63.55,18,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,314.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55,3783,,facility
EVOKED AUDITORY TEST LIMITED,92587,CPT,470,RC,,,,outpatient,,,982,834.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,718.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,681.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,70.45,,,,,,,fee schedule,,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,254.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1113.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,944.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,198,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,197,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,70.45,3783,,facility
NIDA 5 (DOT),08030040,CDM,940,RC,,,,outpatient,,,97,82.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1037,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1037,3783,,facility
OFF/OP CONSLTJ NEW/EST SF 20,99242,CPT,510,RC,,,,outpatient,,,449,381.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
SPECIAL STAINS GROUP 1,88312,CPT,312,RC,,,,outpatient,,,198,168.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,290.49,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,150.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,150.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,198,,,,,,,fee schedule,,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,61.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,55.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,67.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,227.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,67.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59.36,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,59.36,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.02,3783,,facility
IMHCHEM/IMCYTCHM EA ADD ANTB,88341,CPT,310,RC,,,,outpatient,,,320,272,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,235.26,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,68.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,68.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,312.25,,,,,,,fee schedule,,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,28.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,25.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,31.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,104.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,31.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,77.52,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,77.52,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,29.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25.24,3783,,facility
SPECIAL STAINS GROUP 2,88313,CPT,310,RC,,,,outpatient,,,132,112.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,236.58,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,383.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,383.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,132,,,,,,,fee schedule,,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,157.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,685.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,581.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40.12,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40.12,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40.12,3783,,facility
IGH VARI REGIONAL MUTATION,81263,CPT,310,RC,,,,outpatient,,,3048,2590.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1192.14,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,683.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,683.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,294.52,,,,,,,fee schedule,,279.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,294.52,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,309.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1222.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1036.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,309.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,353.42,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,353.42,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,279.79,3783,,facility
CYTOPATH FL NONGYN SMEARS,88104,CPT,311,RC,,,,outpatient,,,507,430.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,148.53,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,107.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,107.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,243.74,,,,,,,fee schedule,,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,44.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,39.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,192.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,163.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,48.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,40.12,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,40.12,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.43,3783,,facility
PATH CONSLTJ SURG CYTO XM EA,88334,CPT,310,RC,,,,outpatient,,,180,153,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,65.73,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,90.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,90.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,180,,,,,,,fee schedule,,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,37.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,33.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,40.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,161.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,137.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,40.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.65,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21.65,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,38.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.65,3783,,facility
CYTOPATH C/V AUTO FLUID REDO,88175,CPT,311,RC,,,,outpatient,,,119,101.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,107.79,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,61.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,61.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.61,,,,,,,fee schedule,,25.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,26.61,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,93.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,27.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.93,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31.93,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25.28,3783,,facility
FMR1 GEN ALY DETC ABNL ALLEL,81243,CPT,310,RC,,,,outpatient,,,990,841.5,,70,,57.04,57.04,57.04,1 through 10,percent of total billed charges,,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,207.66,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,132.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,132.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,160.28,160.28,160.28,15,percent of total billed charges,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57.04,,,,,,,fee schedule,,54.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,57.04,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,188.4,188.4,188.4,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,57.04,57.04,942,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,59.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,236.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,200.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,59.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,68.45,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,68.45,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,54.19,3783,,facility
TISSUE EXAM BY PATHOLOGIST,88302,CPT,312,RC,,,,outpatient,,,413,351.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,89.37,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,107.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,107.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,107.03,,,,,,,fee schedule,,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,44.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,39.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,192.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,163.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,48.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27.59,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,27.59,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27.59,3783,,facility
CYTP DX EVAL FNA 1ST EA SITE,88172,CPT,311,RC,,,,outpatient,,,583,495.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,72.3,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,490.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,490.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,191.33,,,,,,,fee schedule,,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,179.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,201.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,179.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,222.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,878.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,744.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,222.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,172.2,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,172.2,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,72.3,3783,,facility
PLACE CATHETER IN ARTERY,36215,CPT,761,RC,,,,outpatient,,,872,741.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4060,,,,,,,fee schedule,,4060,,,,,,,fee schedule,,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,187.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,209.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,187.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,231.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,914.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,775.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,231.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,187.37,4060,,facility
PSYTX W PT 45 MINUTES,90834,CPT,914,RC,,,,outpatient,,,647,549.95,,70,,100,100,100,1 through 10,percent of total billed charges,,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,110,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,110,,,,,,,case rate,,114,,,,,,,case rate,,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,187.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,209.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,187.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,231.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,914.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,776.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,231.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110,3783,,professional
PHARMACOLOGIC MGMT W/PSYTX,90863,CPT,944,RC,,,,outpatient,,,529,449.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,227,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,226,,,,,,,case rate,,227,,,,,,,case rate,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,226,3783,,facility
PSYTX W PT 30 MINUTES,90832,CPT,914,RC,,,,outpatient,,,616,523.6,,70,,71,71,71,23,percent of total billed charges,,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,570.39,457.08,570.39,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,78,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,78,,,,,,,case rate,,110,,,,,,,case rate,,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,187.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,209.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,187.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,231.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,914.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,25.21,25.21,25.21,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,776.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,231.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,220.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,78,3783,,professional
ENDOVENOUS RF 1ST VEIN,36475,CPT,361,RC,,,,outpatient,,,15711,13354.35,1648,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4091,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4060,,,,,,,fee schedule,,4060,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3726.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16276.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,13805.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,16276.8,,facility
INSERT PICVAD CATH,36570,CPT,361,RC,,,,outpatient,,,9116,7748.6,1648,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3690,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4060,,,,,,,fee schedule,,4060,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3726.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16276.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,13805.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,16276.8,,facility
PLACE CATH SUBCLAVIAN ART,36225,CPT,361,RC,,,,outpatient,,,10820,9197,1648,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4060,,,,,,,fee schedule,,4060,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3726.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16276.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,13805.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,16276.8,,facility
INSERT HEPATIC SHUNT (TIPS),37182,CPT,361,RC,,,,outpatient,,,36978,31431.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4138,,,,,,,fee schedule,,4138,,,,,,,fee schedule,,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21632.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23909.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,94499.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,80153.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,23909.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11505,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11505,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,22770.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3174,94499.48,,facility
THER RADIOLOGY TX PLNG CPLX,77263,CPT,333,RC,,,,outpatient,,,791,672.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,350,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,516.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,163.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,183.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,163.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,202.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,799.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,678.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,202.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1024,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,192.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,163.83,3783,,facility
PLACE CATH VERTEBRAL ART,36226,CPT,361,RC,,,,outpatient,,,18950,16107.5,1648,,,,,,,fee schedule,,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4138,,,,,,,fee schedule,,4138,,,,,,,fee schedule,,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6566.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7257.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28684.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,24330.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,7257.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,28684.88,,facility
NJX PX NFROSGRM &/URTRGRM,50431,CPT,361,RC,,,,outpatient,,,2652,2254.2,344,,,,,,,fee schedule,,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,822.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,909.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3594.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,3048.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,909.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,866.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,344,4051,,facility
DESTROY L/S FACET JNT ADDL,64636,CPT,361,RC,,,,outpatient,,,2522,2143.7,1648,,,,,,,fee schedule,,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,55.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,61.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,241.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,204.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,61.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.2,3783,,facility
TERUMO AZURE CX18 DETACHABLE,02933261,CDM,278,RC,,,,outpatient,,,2232,1897.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PLMT URETERAL STENT PRQ,50693,CPT,361,RC,,,,outpatient,,,8910,7573.5,1648,,,,,,,fee schedule,,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3795,,,,,,,fee schedule,,3795,,,,,,,fee schedule,,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4159.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4597.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18171.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,15412.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4597.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4378.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,18171.27,,facility
STAB PHLEB VEINS XTR 10-20,37765,CPT,361,RC,,,,outpatient,,,10177,8650.45,1648,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3690,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4060,,,,,,,fee schedule,,4060,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3726.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16276.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,13805.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,16276.8,,facility
N BLOCK LUMBAR/THORACIC,64520,CPT,361,RC,,,,outpatient,,,2827,2402.95,1648,,,,,,,fee schedule,,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2086,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1043.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1153.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4559.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,3867.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,1153.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1098.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1043.73,4559.44,,facility
COMPL RPLCMT PICC RS&I,36584,CPT,361,RC,,,,outpatient,,,4086,3473.1,1648,,,,,,,fee schedule,,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2086,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3795,,,,,,,fee schedule,,3795,,,,,,,fee schedule,,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1857.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2053.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8114.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,6882.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2053.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,8114.74,,facility
EGD US FINE NEEDLE BX/ASPIR,43238,CPT,361,RC,,,,outpatient,,,5893,5009.05,1648,,,,,,,fee schedule,,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3370,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3795,,,,,,,fee schedule,,3795,,,,,,,fee schedule,,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2264.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2502.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9891.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,8390.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2502.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5048,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5048,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,9891.94,,facility
NJX SCLRSNT MLT INCMPTNT VN,36471,CPT,361,RC,,,,outpatient,,,564,479.4,344,,,,,,,fee schedule,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,479.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2095.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1777.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,344,3783,,facility
INC&RMVL FB SUBQ TISS SMPL,10120,CPT,361,RC,,,,outpatient,,,1242,1055.7,344,,,,,,,fee schedule,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,479.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2095.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1777.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,344,3783,,facility
EVASC PRLNG ADMN RX AGNT 1ST,61650,CPT,361,RC,,,,outpatient,,,6765,5750.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4291,,,,,,,fee schedule,,4291,,,,,,,fee schedule,,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,620.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,685.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2709.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,2297.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,685.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2583,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2583,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,652.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,620.14,4291,,facility
REMOVE CVA DEVICE OBSTRUCT,75901,CPT,320,RC,,,,outpatient,,,2652,2254.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,722.91,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,69.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,75.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,613.7,,,,,,,fee schedule,,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,24.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,21.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,26.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,105.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,89.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,26.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,25.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.68,3783,,facility
CYSTOSCOPY AND TREATMENT,52310,CPT,361,RC,,,,outpatient,,,5318,4520.3,1648,,,,,,,fee schedule,,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3370,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3795,,,,,,,fee schedule,,3795,,,,,,,fee schedule,,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2466.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2726.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10775.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,9140.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2726.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5048,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5048,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,10775.89,,facility
THROMBOLYTIC ART THERAPY,37211,CPT,361,RC,,,,outpatient,,,17331,14731.35,1648,,,,,,,fee schedule,,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4138,,,,,,,fee schedule,,4138,,,,,,,fee schedule,,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6566.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7257.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28684.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,24330.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,7257.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,28684.88,,facility
INSERT TUNNELED CV CATH,36560,CPT,361,RC,,,,outpatient,,,8941,7599.85,1648,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3690,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4060,,,,,,,fee schedule,,4060,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3726.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16276.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,13805.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,16276.8,,facility
PERCUT ABLATE LIVER RF,47382,CPT,361,RC,,,,outpatient,,,21016,17863.6,1648,,,,,,,fee schedule,,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6598.97,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4200,,,,,,,fee schedule,,4200,,,,,,,fee schedule,,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7134.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7885.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31164.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,26433.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,7885.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7509.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,31164.63,,facility
INJ PARAVERT F JNT L/S 2 LEV,64494,CPT,361,RC,,,,outpatient,,,740,629,1648,,,,,,,fee schedule,,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,206.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,175.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,52.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,47.23,3783,,facility
SCLEROTX FLUID COLLECTION,49185,CPT,361,RC,,,,outpatient,,,3626,3082.1,1648,,,,,,,fee schedule,,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1948.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2154.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8513.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,7221.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2154.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1465,8513.97,,facility
"CATH, THROMBECTOMY/EMBOLECT",C1757,HCPCS,278,RC,,,,outpatient,,,31500,26775,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
DESTROY C/TH FACET JNT ADDL,64634,CPT,361,RC,,,,outpatient,,,2522,2143.7,1648,,,,,,,fee schedule,,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,62.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,69.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,273.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,232.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,69.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.7,3783,,facility
PLACE DUOD/JEJ TUBE PERC,49441,CPT,361,RC,,,,outpatient,,,5738,4877.3,790,,,,,,,fee schedule,,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2086,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3795,,,,,,,fee schedule,,3795,,,,,,,fee schedule,,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2264.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2502.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9891.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,8390.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2502.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5048,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5048,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,790,9891.94,,facility
REDO ENDOVAS VENA CAVA FILTR,37192,CPT,361,RC,,,,outpatient,,,8941,7599.85,1648,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4060,,,,,,,fee schedule,,4060,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3726.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16276.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,13805.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,16276.8,,facility
CHEMO IA PUSH TECNIQUE,96420,CPT,331,RC,,,,outpatient,,,583,495.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1099.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1036,,,,,,,case rate,,872,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,348.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,389.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,348.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,430.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1682.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1427.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,430.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1117,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,348.76,3783,,facility
TRLUML BALO ANGIOP 1ST VEIN,37248,CPT,361,RC,,,,outpatient,,,21380,18173,1648,,,,,,,fee schedule,,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4291,,,,,,,fee schedule,,4291,,,,,,,fee schedule,,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6716.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7423.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7126,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,7554,,,,,,,case rate,,7423.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,10449,,facility
INS CATH ABD/L-EXT ART 1ST,36245,CPT,361,RC,,,,outpatient,,,2652,2254.2,1648,,,,,,,fee schedule,,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4138,,,,,,,fee schedule,,4138,,,,,,,fee schedule,,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,234.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,258.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1022.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,867.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,258.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,246.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,234.18,4138,,facility
DESTROY LUMB/SAC FACET JNT,64635,CPT,361,RC,,,,outpatient,,,6174,5247.9,1648,,,,,,,fee schedule,,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3795,,,,,,,fee schedule,,3795,,,,,,,fee schedule,,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2304.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2546.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10066.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,8538.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2546.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6310,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6310,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2425.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,10066.32,,facility
MR GUIDED P.T.ABLATION,02211314,CDM,361,RC,,,,outpatient,,,2986,2538.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3174,3783,,facility
NASAL/OROGASTRIC W/TUBE PLMT,43752,CPT,361,RC,,,,outpatient,,,600,510,344,,,,,,,fee schedule,,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,527.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,582.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2302.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1953.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,582.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,344,3783,,facility
MICRO WIRE .014-TENOR,02211332,CDM,272,RC,,,,outpatient,,,1023,869.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PLACE CATH CAROTID/INOM ART,36222,CPT,361,RC,,,,outpatient,,,10820,9197,1648,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4060,,,,,,,fee schedule,,4060,,,,,,,fee schedule,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3726.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16276.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,13805.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,16276.8,,facility
BIOPSY OF THYROID,60100,CPT,361,RC,,,,outpatient,,,1691,1437.35,790,,,,,,,fee schedule,,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2086,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,835.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,923.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3650.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,3096.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,923.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,790,4051,,facility
REPLACE CVAD CATH,36580,CPT,361,RC,,,,outpatient,,,3160,2686,1648,,,,,,,fee schedule,,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2086,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3795,,,,,,,fee schedule,,3795,,,,,,,fee schedule,,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1857.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2053.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8114.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,6882.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2053.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,8114.74,,facility
IMAGE CATH FLUID COLXN VISC,49405,CPT,361,RC,,,,outpatient,,,6103,5187.55,1648,,,,,,,fee schedule,,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3795,,,,,,,fee schedule,,3795,,,,,,,fee schedule,,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1948.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2154.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8513.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,7221.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2154.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5048,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5048,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2051.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,8513.97,,facility
TRLUML BALO ANGIOP 1ST ART,37246,CPT,361,RC,,,,outpatient,,,21380,18173,1648,,,,,,,fee schedule,,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4291,,,,,,,fee schedule,,4291,,,,,,,fee schedule,,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6716.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7423.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,29340,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,24885.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,7423.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7069.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,29340,,facility
OFF/OP CONSLTJ NEW/EST HI 55,99245,CPT,510,RC,,,,outpatient,,,1131,961.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
PERQ CERVICOTHORACIC INJECT,22510,CPT,361,RC,,,,outpatient,,,11429,9714.65,1648,,,,,,,fee schedule,,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4060,,,,,,,fee schedule,,4060,,,,,,,fee schedule,,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3861.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4267.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16867.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,14306.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4267.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,16867.18,,facility
REMOVE URETER STENT PERCUT,50384,CPT,361,RC,,,,outpatient,,,5880,4998,1648,,,,,,,fee schedule,,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2086,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3795,,,,,,,fee schedule,,3795,,,,,,,fee schedule,,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2466.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2726.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10775.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,9140.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2726.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6310,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6310,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2596.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,10775.89,,facility
PERQ NL/PL LITHOTRP SMPL<2CM,50080,CPT,361,RC,,,,outpatient,,,16940,14399,1648,,,,,,,fee schedule,,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5317.9,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4335,,,,,,,fee schedule,,4335,,,,,,,fee schedule,,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11170.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12346.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48799.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,41391.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,12346.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9040,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9040,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11758.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,48799.56,,facility
REPLACE TUNNELED CV CATH,36583,CPT,361,RC,,,,outpatient,,,11579,9842.15,1648,,,,,,,fee schedule,,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3690,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4138,,,,,,,fee schedule,,4138,,,,,,,fee schedule,,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6566.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7257.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28684.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,24330.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,7257.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,28684.88,,facility
PIGATIL CATH 7FR,05710109,CDM,272,RC,,,,outpatient,,,336,285.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
REPAIR TUNNELED CV CATH,36576,CPT,361,RC,,,,outpatient,,,3160,2686,1648,,,,,,,fee schedule,,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3370,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3795,,,,,,,fee schedule,,3795,,,,,,,fee schedule,,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1857.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2053.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8114.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,6882.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2053.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,8114.74,,facility
UNLISTED PX VASCULAR SURGERY,37799,CPT,361,RC,,,,outpatient,,,3944,3352.4,1648,,,,,,,fee schedule,,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,740.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,818.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3233.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,2742.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,818.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,779.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,740.25,4051,,facility
INJECT SINUS TRACT FOR X-RAY,20501,CPT,361,RC,,,,outpatient,,,2652,2254.2,344,,,,,,,fee schedule,,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,146.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,124.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,37.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,35.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.64,3783,,facility
UNLISTED PROCEDURE LIVER,47399,CPT,361,RC,,,,outpatient,,,1803,1532.55,790,,,,,,,fee schedule,,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,835.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,923.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3650.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,3096.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,923.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,790,4051,,facility
INSERT TUNNELED CV CATH,36563,CPT,361,RC,,,,outpatient,,,8941,7599.85,1648,,,,,,,fee schedule,,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3690,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4138,,,,,,,fee schedule,,4138,,,,,,,fee schedule,,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6566.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7257.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28684.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,24330.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,7257.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6912.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,28684.88,,facility
ABLATE BONE TUMOR(S) PERQ,20982,CPT,361,RC,,,,outpatient,,,17855,15176.75,1648,,,,,,,fee schedule,,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5605.81,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4291,,,,,,,fee schedule,,4291,,,,,,,fee schedule,,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,20690.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,22868.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,90386.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,76665.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,22868.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9040,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9040,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,21779.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,90386.71,,facility
UNLISTED MR PROCEDURE,76498,CPT,610,RC,,,,outpatient,,,6483,5510.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2127,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3610,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,296.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,318.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3641,,,,,,,case rate,,3641,,,,,,,case rate,,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,91.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,102.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,91.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,113.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,448.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,380.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,113.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,108.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,91.88,3641,,facility
MAJOR PACK - OR,01203526,CDM,272,RC,,,,outpatient,,,553,470.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ARTHROSCOPY SHOULDER PACK-OR,01207442,CDM,272,RC,,,,outpatient,,,362,307.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CATHETER SINUS GUIDE (GC070),01410004,CDM,272,RC,,,,outpatient,,,2040,1734,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
HANDLE SINUS CATH GUIDE(SDKK01,01410003,CDM,272,RC,,,,outpatient,,,370,314.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
PIKPAK DR. KAGAN ALCON,01234205,CDM,272,RC,,,,outpatient,,,758,644.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
"CATH, TRANSLUMIN NON-LASER",C1725,HCPCS,278,RC,,,,outpatient,,,1264,1074.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
KNEE ARTHROSCOPY/SURGERY,29881,CPT,361,RC,,,,outpatient,,,9056,7697.6,1648,,,,,,,fee schedule,,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3690,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4060,,,,,,,fee schedule,,4060,,,,,,,fee schedule,,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3861.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4267.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16867.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,14306.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4267.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7573,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4064.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1648,16867.18,,facility
THER/PROPH/DIAG INJ IV PUSH,96374,CPT,260,RC,,,,outpatient,,,431,366.35,,70,,69,69,69,1 through 10,percent of total billed charges,,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,212.3,212.3,225.5,1 through 10,percent of total billed charges,,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,224.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,251,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,224.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,42.36,42.36,410,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,277.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,28.3,28.3,28.3,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,28.3,28.3,28.3,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1083.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,919.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,277.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,224.58,3783,,facility
CHEMO IV INFUSION ADDL HR,96415,CPT,335,RC,,,,outpatient,,,342,290.7,,70,,44,44,44,1 through 10,percent of total billed charges,,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,239.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1036,,,,,,,case rate,,872,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,357.5,168.3,357.5,17,percent of total billed charges,,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,76.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,84.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,76.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.05,5.05,5.05,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,366.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,311.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1117,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,76.02,3783,,facility
THER/PROPH/DIAG IV INF INIT,96365,CPT,260,RC,,,,outpatient,,,1309,1112.65,,70,,87,87,87,35,percent of total billed charges,,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,874.23,874.23,874.23,1 through 10,percent of total billed charges,,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,35.35,35.35,353.8,31,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,685.3,513.98,692.01,202,percent of total billed charges,,,55,,685.3,685.3,755.28,36,percent of total billed charges,,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,224.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,251,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,224.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,309.04,37.84,646.25,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,341.53,341.53,341.53,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,277.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,79.54,79.54,726.19,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,35.35,35.35,35.35,46,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1083.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,76,76,760.67,18,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,919.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,277.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,224.58,3783,,facility
REFILL/MAINT PORTABLE PUMP,96521,CPT,335,RC,,,,outpatient,,,1223,1039.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,708.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1036,,,,,,,case rate,,872,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,224.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,251,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,224.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,277.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1083.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,919.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,277.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1117,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,264.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,224.58,3783,,facility
"BRACHYTX, NON-STRANDED,I-125",C2639,HCPCS,278,RC,,,,outpatient,,,196,166.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,30.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,38.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,38.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,36.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,30.99,3783,,facility
EIC 4845-01 ULTRA REFL 45DEGRE,01410010,CDM,272,RC,,,,outpatient,,,1068,907.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
TX/PRO/DX INJ NEW DRUG ADDON,96375,CPT,260,RC,,,,outpatient,,,246,209.1,,70,,30,30,90,17,percent of total billed charges,,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,257.4,128.7,423.28,69,percent of total billed charges,,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,55.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,49.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,23.62,23.62,23.62,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,23.62,11.81,35.43,20,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,238.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,202.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.44,3783,,facility
CHEMOTHERAPY INTO CNS,96450,CPT,331,RC,,,,outpatient,,,939,798.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1099.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1036,,,,,,,case rate,,872,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,348.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,389.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,348.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,430.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1682.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1427.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,430.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1117,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,348.75,3783,,facility
CHEMO PROLONG INFUSE W/PUMP,96416,CPT,335,RC,,,,outpatient,,,1309,1112.65,,70,,217,217,217,13,percent of total billed charges,,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1099.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1036,,,,,,,case rate,,872,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,348.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,389.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,348.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,430.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,35.35,35.35,35.35,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1682.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1427.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,430.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1117,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,348.75,3783,,facility
TX/PROPH/DG ADDL SEQ IV INF,96367,CPT,260,RC,,,,outpatient,,,260,221,,70,,43,43,43,15,percent of total billed charges,,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,135.85,135.85,135.85,19,percent of total billed charges,,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,76.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,84.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,76.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,22.73,22.73,22.73,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.05,5.05,5.05,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,366.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,734.29,734.29,734.29,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,311.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,76.02,3783,,facility
THER/PROPH/DIAG IV INF ADDON,96366,CPT,260,RC,,,,outpatient,,,180,153,,70,,108,108,108,1 through 10,percent of total billed charges,,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,94.05,94.05,94.05,1 through 10,percent of total billed charges,,,55,,94.05,94.05,94.05,1 through 10,percent of total billed charges,,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,55.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,49.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.05,5.05,353.8,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,238.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,202.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.44,3783,,facility
IV SOLUTIONS,01505099,CDM,258,RC,,,,inpatient,,,201,170.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
DECLOT VASCULAR DEVICE,36593,CPT,360,RC,,,,outpatient,,,1062,902.7,344,,,,,,,fee schedule,,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,389.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,430.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1702.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1444.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,430.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,410.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,344,3783,,facility
THER/DIAG CONCURRENT INF,96368,CPT,260,RC,,,,outpatient,,,92,78.2,,70,,25,25,25,11,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,47.85,47.85,47.85,18,percent of total billed charges,,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.05,5.05,5.05,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",5.05,5.05,5.05,1 through 10,other,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,3783,,facility
GEN TROCAR PIN 1/8X3,02712722,CDM,270,RC,,,,outpatient,,,123,104.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
MALLINCKRODT OPTIRAY 350 100ML,02907405,CDM,250,RC,,,,inpatient,,,117,99.45,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
INSERT EMERGENCY AIRWAY,31500,CPT,361,RC,,,,outpatient,,,1174,997.9,344,,,,,,,fee schedule,,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2086,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,279.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,308.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1220.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1035.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,308.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,279.5,3783,,facility
NJX CGEN CAR CATH SLCTV OPAC,93564,CPT,481,RC,,,,outpatient,,,1184,1006.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8512,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6552,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,6609,,,,,,,case rate,,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,54.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,48.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,60.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,238,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,201.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,60.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,57.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48.75,8512,,facility
NJX CGEN CAR CTH SLCTV C ANG,93563,CPT,481,RC,,,,outpatient,,,828,703.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8512,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6552,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,6609,,,,,,,case rate,,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,49.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,44.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,54.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,184.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,54.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,52.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44.46,8512,,facility
NJX CAR CTH SPRVLV AORTGRPHY,93567,CPT,481,RC,,,,outpatient,,,1042,885.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8512,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6552,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,6609,,,,,,,case rate,,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,37.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,33.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,162.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,138.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,41.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,39.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.36,8512,,facility
"ILIAC ART ANGIO,CARDIAC CATH",G0278,HCPCS,481,RC,,,,outpatient,,,8652,7354.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6552,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,50.33,,,,,,,fee schedule,,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,13.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,12.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,50.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,14.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.1,6552,,facility
CORDIS INFINITI 4Fr RCB 100cm,02907406,CDM,278,RC,,,,outpatient,,,70,59.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CORDIS 6FR AVANTI+STD SHEATH,02907371,CDM,278,RC,,,,outpatient,,,70,59.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
VASCULAR SOLUTION 4Fr MICRO,02907407,CDM,272,RC,,,,outpatient,,,174,147.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
IV/TUBING MERIT 72CONST INJ.,05710039,CDM,272,RC,,,,outpatient,,,25,21.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
INSERT I-AORT PERCUT DEVICE,33967,CPT,360,RC,,,,outpatient,,,1669,1418.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3795,,,,,,,fee schedule,,3795,,,,,,,fee schedule,,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,258.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,285.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1128.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,957.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,285.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12679,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12679,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,271.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,258.3,12679,,facility
CORDIS INFINITI 4Fr JR 5.0,02907368,CDM,278,RC,,,,outpatient,,,70,59.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
COOK.018 AUSTRALIAN WIRE 40CM,02907385,CDM,278,RC,,,,outpatient,,,227,192.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
MERIT 72CONTRAST INJ.LINE TUB,02907401,CDM,272,RC,,,,outpatient,,,26,22.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
OBSTETRICAL CARE,59409,CPT,720,RC,,,,inpatient,,,7531,6401.35,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
SPINAL ANESTHESIA TRAY,01101017,CDM,270,RC,,,,outpatient,,,107,90.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
HEART/LUNG RESUSCITATION CPR,92950,CPT,480,RC,,,,outpatient,,,1609,1367.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1257.52,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,718.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,681.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,618,,,,,,,fee schedule,,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,254.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1113.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,944.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1037,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,227.98,3783,,facility
R&L HRT ART/VENTRICLE ANGIO,93460,CPT,481,RC,,,,outpatient,,,16726,14217.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8512,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6552,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,6609,,,,,,,case rate,,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3422.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,3825.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,3422.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4228.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16712.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,14175.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4228.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9040,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9040,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3174,16712.13,,facility
R&L HRT ART/VENTRICLE ANGIO,93461,CPT,481,RC,,,,outpatient,,,16726,14217.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8512,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6552,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,6609,,,,,,,case rate,,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3422.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,3825.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,3422.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4228.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16712.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,14175.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4228.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9040,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9040,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3174,16712.13,,facility
ARGON 36 PRESSUER TUBING,02907400,CDM,272,RC,,,,outpatient,,,21,17.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
R HRT CORONARY ARTERY ANGIO,93456,CPT,481,RC,,,,outpatient,,,15798,13428.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8512,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6552,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,6609,,,,,,,case rate,,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3422.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,3825.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,3422.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4228.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16712.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,14175.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4228.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9040,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9040,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3174,16712.13,,facility
MEDLINE CUSTOM DIAGNOSTIC PACK,02907364,CDM,272,RC,,,,outpatient,,,254,215.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
INSERT ELECTRD/PM CATH SNGL,33210,CPT,481,RC,,,,outpatient,,,21499,18274.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6552,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4335,,,,,,,fee schedule,,4335,,,,,,,fee schedule,,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8737.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,9765.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,8737.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10793.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42659.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,36183.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,10793.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10449,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10279.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3174,42659.59,,facility
NJX CAR CTH SLCTV LV/LA ANG,93565,CPT,481,RC,,,,outpatient,,,386,328.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8512,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6552,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,6609,,,,,,,case rate,,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,27.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,24.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,29.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,117.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,100.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,29.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,28.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.17,8512,,facility
HOSPIRA 7 Fr SWAN THERMODILUTI,02907386,CDM,278,RC,,,,outpatient,,,191,162.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
COOK .014 AUSTRALIA WIRE 40CM,02907392,CDM,278,RC,,,,outpatient,,,227,192.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
EDWARDS LIFESCIENCES 6Fr SWAN,02907370,CDM,278,RC,,,,outpatient,,,895,760.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
TERUMO TR BAND,02907372,CDM,278,RC,,,,outpatient,,,308,261.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CORONARY ART/GRFT ANGIO S&I,93455,CPT,481,RC,,,,outpatient,,,15798,13428.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8512,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6552,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,6609,,,,,,,case rate,,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3422.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,3825.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,3422.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4228.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16712.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,14175.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4228.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9040,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9040,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3174,16712.13,,facility
BOSTON SCIENTIFIC ZIPWIRE,05710049,CDM,278,RC,,,,outpatient,,,262,222.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
RIGHT HEART CATH,93451,CPT,481,RC,,,,outpatient,,,16726,14217.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8512,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6552,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6609,,,,,,,case rate,,6609,,,,,,,case rate,,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3422.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,3825.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,3422.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4228.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16712.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,14175.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4228.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9040,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9040,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4027.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3174,16712.13,,facility
US EXAM PELVIC LIMITED,76857,CPT,402,RC,,,,outpatient,,,894,759.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,89.37,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,473.51,,,,,,,fee schedule,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,89.37,3783,,facility
FETAL CONTRACT STRESS TEST,59020,CPT,720,RC,,,,inpatient,,,1027,872.95,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
MIDDLE CEREBRAL ARTERY ECHO,76821,CPT,402,RC,,,,outpatient,,,894,759.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,207.66,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,509.2,,,,,,,fee schedule,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
OB US < 14 WKS ADDL FETUS,76802,CPT,402,RC,,,,outpatient,,,1190,1011.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,80.19,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,121.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,130.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,217.47,,,,,,,fee schedule,,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,42.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,37.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,46.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,184.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,156.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,46.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,44.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,37.71,3783,,facility
FLUOROGUIDE FOR VEIN DEVICE,77001,CPT,320,RC,,,,outpatient,,,689,585.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,287.85,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,55.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,60.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,287.63,,,,,,,fee schedule,,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,19.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,17.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,21.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,84.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,71.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,21.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,20.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.34,3783,,facility
AMNIOCENTESIS THERAPEUTIC,59001,CPT,361,RC,,,,outpatient,,,2816,2393.6,790,,,,,,,fee schedule,,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,359.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,397.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1570.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1332.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,397.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,359.6,3783,,facility
OB US DETAILED SNGL FETUS,76811,CPT,402,RC,,,,outpatient,,,1395,1185.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,308.88,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,812.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,874.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,714.36,,,,,,,fee schedule,,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,251.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,281.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,251.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,311.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1229.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1043.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,311.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,368.21,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,368.21,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,251.92,3783,,facility
VASCULAR STUDY,93975,CPT,921,RC,,,,outpatient,,,1947,1654.95,,70,,268,268,268,1 through 10,percent of total billed charges,,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1675.65,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,794.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,752.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,980.52,,,,,,,fee schedule,,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,251.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,281.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,251.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,311.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1229.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1043.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,311.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1037,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,251.92,3783,,facility
OB US >= 14 WKS ADDL FETUS,76810,CPT,402,RC,,,,outpatient,,,1131,961.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,157.71,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,145.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,156.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,314.66,,,,,,,fee schedule,,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,50.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,45.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,55.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,220.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,186.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,55.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45.14,3783,,facility
OFF/OP CNSLTJ NEW/EST MOD 40,99244,CPT,510,RC,,,,outpatient,,,902,766.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
BIOPSY OF UTERUS LINING,58100,CPT,761,RC,,,,outpatient,,,1490,1266.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,213.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,238.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,213.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,263.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1042.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,883.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,263.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,213.46,3783,,facility
ENDOSCOPY RM TIME 240 MINUTES,00901015,CDM,360,RC,,,,outpatient,,,8203,6972.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3174,3783,,facility
ENDOSCOPY RM TIME 45 MINUTES,00901002,CDM,360,RC,,,,outpatient,,,4986,4238.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3174,3783,,facility
ENDOSCOPY ROOM TIME 90 MINUTES,00901005,CDM,360,RC,,,,outpatient,,,4986,4238.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3174,3783,,facility
AMBULATORY CARE VISIT (SAT),00901016,CDM,761,RC,,,,outpatient,,,1735,1474.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
ENDOSCOPY RM TIME 1 MINUTE,01202071,CDM,360,RC,,,,outpatient,,,156,132.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3174,3783,,facility
ENDOSCOPY ROOM TIME 75 MINUTES,00901004,CDM,360,RC,,,,outpatient,,,4176,3549.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3174,3783,,facility
UNLISTED URINALYSIS PX,81099,CPT,309,RC,,,,outpatient,,,390,331.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,50,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,50,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
AUTOMATED RBC COUNT,85041,CPT,305,RC,,,,outpatient,,,58,49.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.82,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,7.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,7.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10.48,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.02,,,,,,,fee schedule,,2.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,3.02,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,6.82,6.82,6.82,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,10.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,3.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.62,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.62,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.87,3783,,facility
COMPLETE CBC AUTOMATED,85027,CPT,305,RC,,,,outpatient,,,145,123.25,,70,,9,9,9,311,percent of total billed charges,,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.28,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,15.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,15.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,4.16,4.16,22.42,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,3.2,3.2,7.2,67,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,7.2,7.2,7.2,19,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,22.42,,,,,,,fee schedule,,,85,,22.42,16.82,24.46,85,percent of total billed charges,,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.47,,,,,,,fee schedule,,6.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,6.47,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,3.96,3.17,4,106,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,3.17,3.17,3.2,468,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,3.43,3.43,11.96,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,7.2,7.2,25.13,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,3.2,3.2,11.17,16,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,6.88,4.09,6.88,160,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,22.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,6.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.76,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.76,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.15,3783,,facility
MANUAL CELL COUNT EACH,85032,CPT,305,RC,,,,outpatient,,,145,123.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.1,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,10,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,10,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14.95,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.31,,,,,,,fee schedule,,4.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,4.31,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,15.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.17,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.17,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.09,3783,,facility
OCCULT BLOOD OTHER SOURCES,82271,CPT,301,RC,,,,outpatient,,,117,99.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19.71,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,12.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,12.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14.95,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.32,,,,,,,fee schedule,,5.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,5.32,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,18.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,5.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.38,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.38,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.05,3783,,facility
BODY FLUID CELL COUNT,89050,CPT,309,RC,,,,outpatient,,,105,89.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19.71,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,10.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,10.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16.38,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.72,,,,,,,fee schedule,,4.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,4.72,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,16.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.66,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.66,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.48,3783,,facility
DX LARYNGOSCOPY EXCL NB,31525,CPT,450,RC,,,,outpatient,,,5324,4525.4,826,,,,,,,case rate,,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2100.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2321.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,7782.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2321.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,7782.47,,facility
TX GASTRO INTUB W/ASP,43753,CPT,450,RC,,,,outpatient,,,1035,879.75,826,,,,,,,case rate,,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,254.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,944.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,254.8,1548,,facility
CHROMOGENIC SUBSTRATE ASSAY,85130,CPT,305,RC,,,,outpatient,,,257,218.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48.63,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,27.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,27.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41.25,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.89,,,,,,,fee schedule,,11.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,11.89,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,41.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,12.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.27,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.27,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.3,3783,,facility
UNLISTED PROCEDURE COLON,45399,CPT,450,RC,,,,outpatient,,,3164,2689.4,826,,,,,,,case rate,,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1097.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1212.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,4066.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,1212.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,4066.16,,facility
COMPLETE CBC W/AUTO DIFF WBC,85025,CPT,305,RC,,,,outpatient,,,145,123.25,,70,,11,11,11,499,percent of total billed charges,,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.56,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,18.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,18.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,19.77,19.77,19.77,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,3.2,3.2,4.16,14,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,3.2,3.2,7.2,55,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,7.2,7.2,7.2,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,26.95,,,,,,,fee schedule,,,85,,20.21,4.16,26.95,85,percent of total billed charges,,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.77,,,,,,,fee schedule,,7.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,7.77,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,3.2,3.2,4,133,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,3.2,3.2,3.2,426,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,11.96,11.96,18.48,21,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,7.2,7.2,7.2,14,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,3.2,3.2,3.2,167,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,6.88,4.09,6.88,110,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,27.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,8.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.32,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9.32,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,7.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.38,3783,,facility
INTRO NDL ICATH UPR/LXTR ART,36140,CPT,450,RC,,,,outpatient,,,2652,2254.2,826,,,,,,,case rate,,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,90.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,99.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,333.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,99.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,94.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,90.06,1548,,facility
RPR LIP FTH VERMILION ONLY,40650,CPT,450,RC,,,,outpatient,,,2298,1953.3,826,,,,,,,case rate,,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,636.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,703.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,2358.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,703.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,636.44,2358.19,,facility
CARDIOVERSION ELECTRIC EXT,92960,CPT,450,RC,,,,outpatient,,,3071,2610.35,826,,,,,,,case rate,,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,779.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,862.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,2889.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,862.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,821.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,779.96,2889.96,,facility
RPR F/E/E/N/L/M 2.6-5.0 CM,12013,CPT,450,RC,,,,outpatient,,,808,686.8,826,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,236.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,823.94,823.94,823.94,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,877.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,236.76,1548,,facility
SHIGA-LIKE TOXIN AG IA,87427,CPT,306,RC,,,,outpatient,,,51,43.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48.63,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,27.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,27.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,41.59,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.98,,,,,,,fee schedule,,11.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,11.98,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,42.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,12.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.38,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.38,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.38,3783,,facility
LEGIONELLA ANTIBODY,86713,CPT,302,RC,,,,outpatient,,,241,204.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,61.77,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,35.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,35.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,53.08,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.3,,,,,,,fee schedule,,14.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,15.3,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,63.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,53.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,16.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.36,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18.36,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.54,3783,,facility
URINALYSIS AUTO W/O SCOPE,81003,CPT,307,RC,,,,outpatient,,,124,105.4,,70,,4,4,4,343,percent of total billed charges,,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.21,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,5.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,2.63,2.63,2.63,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,2.02,2.02,2.02,28,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,4.55,4.55,4.55,12,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,7.78,,,,,,,fee schedule,,,85,,7.78,5.84,7.78,116,percent of total billed charges,,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.25,,,,,,,fee schedule,,2.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,2.25,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,2.53,2.02,2.53,56,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,2.02,2.02,2.02,193,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,11.4,2.16,11.4,13,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,4.55,4.55,23.96,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,2.02,2.02,2.02,61,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,4.34,4.34,4.34,118,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,7.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.7,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2.7,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2.14,3783,,facility
MANUAL RETICULOCYTE COUNT,85044,CPT,305,RC,,,,outpatient,,,124,105.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.1,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,10,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,10,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14.95,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.31,,,,,,,fee schedule,,4.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,4.31,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,15.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.17,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.17,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.09,3783,,facility
RBC SICKLE CELL TEST,85660,CPT,305,RC,,,,outpatient,,,35,29.75,,70,,6,6,12,30,percent of total billed charges,,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.35,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,12.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,12.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,19.11,,,,,,,fee schedule,,,85,,14.33,14.33,19.11,1 through 10,percent of total billed charges,,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.51,,,,,,,fee schedule,,5.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,5.51,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,4.28,4.28,6.84,41,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,3.42,3.42,3.42,127,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,27.2,5.97,27.2,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,4.56,4.56,4.56,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,4.56,4.56,9.12,14,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,19.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,5.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.61,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.61,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.23,3783,,facility
ADD AUTOMATED HEMOGRAM INDICES,02031005,CDM,305,RC,,,,outpatient,,,52,44.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 232.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 232.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 232.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 232.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,3783,,facility
URINE PREGNANCY TEST,81025,CPT,307,RC,,,,outpatient,,,171,145.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.56,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,19.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,19.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24.19,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.61,,,,,,,fee schedule,,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,8.61,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,30.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,9.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.33,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10.33,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.18,3783,,facility
RPLC GTUBE NO REVJ TRC,43762,CPT,450,RC,,,,outpatient,,,926,787.1,826,,,,,,,case rate,,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,294.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,325.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1092.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,325.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,310.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,294.83,1548,,facility
REMOVE FOREIGN BODY FROM EYE,65205,CPT,450,RC,,,,outpatient,,,449,381.65,826,,,,,,,case rate,,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,157.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,581.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,157.01,1548,,facility
EXPL PENTRG WND ABD/FLNK/BK,20102,CPT,450,RC,,,,outpatient,,,6180,5253,826,,,,,,,case rate,,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2434.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2691.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,9021.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2691.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2562.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,9021.55,,facility
INSERTION CATHETER ARTERY,36620,CPT,450,RC,,,,outpatient,,,185,157.25,826,,,,,,,case rate,,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,43.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,162.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,48.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,43.83,1548,,facility
RPR S/N/A/GEN/TRK20.1-30.0CM,12006,CPT,450,RC,,,,outpatient,,,1469,1248.65,826,,,,,,,case rate,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,479.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1777.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,479.71,1777.46,,facility
URINE CULTURE/COLONY COUNT,87086,CPT,306,RC,,,,outpatient,,,297,252.45,,70,,12,12,12,88,percent of total billed charges,,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32.85,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,18.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,18.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,10.49,10.49,10.49,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,8.07,8.07,8.07,29,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27.99,,,,,,,fee schedule,,,85,,27.99,18.16,27.99,52,percent of total billed charges,,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.07,,,,,,,fee schedule,,7.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,8.07,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,10.09,8.07,10.09,67,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,8.07,8.07,8.07,161,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,8.64,8.64,10.45,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,21.96,21.96,21.96,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,8.07,8.07,8.07,12,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,17.35,17.35,17.35,43,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,28.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,8.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.67,3783,,facility
STREP A AG IA,87430,CPT,306,RC,,,,outpatient,,,70,59.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,61.77,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,47.24,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16.81,,,,,,,fee schedule,,15.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,16.81,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,69.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,59.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,17.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.17,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20.17,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.97,3783,,facility
PM DEVICE PROGR EVAL DUAL,93280,CPT,480,RC,,,,outpatient,,,145,123.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,124.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,117.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,145,,,,,,,fee schedule,,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,44.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,39.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,192.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,163.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,48.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1037,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.41,3783,,facility
LARYNGOSCOPY W/FB REMOVAL,31530,CPT,450,RC,,,,outpatient,,,4862,4132.7,826,,,,,,,case rate,,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2100.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2321.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,7782.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2321.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,7782.47,,facility
TREAT BIG TOE FRACTURE,28495,CPT,450,RC,,,,outpatient,,,737,626.45,826,,,,,,,case rate,,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,291.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,321.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1078.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,321.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,291.08,1548,,facility
REMOVE FOREIGN BODY FROM EYE,65210,CPT,450,RC,,,,outpatient,,,1371,1165.35,826,,,,,,,case rate,,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,527.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,582.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1953.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,582.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,554.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,527.16,1953.28,,facility
TREAT FINGER FRACTURE EACH,26742,CPT,450,RC,,,,outpatient,,,5012,4260.2,826,,,,,,,case rate,,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1897.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2097.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,7030.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2097.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,7030.81,,facility
TREAT KNEECAP DISLOCATION,27560,CPT,450,RC,,,,outpatient,,,905,769.25,826,,,,,,,case rate,,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,291.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,321.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1078.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,321.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,291.08,1548,,facility
INSERT INTRAUTERINE DEVICE,58300,CPT,450,RC,,,,outpatient,,,738,627.3,826,,,,,,,case rate,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,813,1548,,facility
UNLISTED PULMONARY SVC/PX,94799,CPT,460,RC,,,,outpatient,,,685,582.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,428.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,151.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,135.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,167.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,663.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,562.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,167.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135.86,3783,,facility
REPAIR BLOOD VESSEL DIR UXTR,35206,CPT,450,RC,,,,outpatient,,,10451,8883.35,826,,,,,,,case rate,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3726.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,13805.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,13805.86,,facility
DIAGNOSTIC COLONOSCOPY,45378,CPT,450,RC,,,,outpatient,,,2963,2518.55,826,,,,,,,case rate,,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1097.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1212.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,4066.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,1212.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,4066.16,,facility
EGD PLACE GASTROSTOMY TUBE,43246,CPT,450,RC,,,,outpatient,,,6145,5223.25,826,,,,,,,case rate,,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2264.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2502.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,8390.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2502.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2383.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,8390.27,,facility
CMPLX RPR S/A/L 1.1-2.5 CM,13120,CPT,450,RC,,,,outpatient,,,844,717.4,826,,,,,,,case rate,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,479.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1777.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,479.71,1777.46,,facility
UNLISTED PROCEDURE NOSE,30999,CPT,450,RC,,,,outpatient,,,360,306,826,,,,,,,case rate,,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,279.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,308.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1035.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,308.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,279.5,1548,,facility
DRG XTRNL EAR ABSC/HEM SMPL,69000,CPT,450,RC,,,,outpatient,,,1075,913.75,826,,,,,,,case rate,,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,835.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,923.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,3096.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,923.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,879.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,3096.26,,facility
ORTHOPOXVIRUS AMP PRB EACH,87593,CPT,306,RC,,,,outpatient,,,158,134.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,119.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,119.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51.31,,,,,,,fee schedule,,48.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,51.31,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,53.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,212.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,180.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,53.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,51.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48.74,3783,,facility
STRAPPING UNNA BOOT,29580,CPT,450,RC,,,,outpatient,,,813,691.05,826,,,,,,,case rate,,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,191.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,211.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,710.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,211.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,201.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,191.77,1548,,facility
HEMODIALYSIS ONE EVALUATION,90935,CPT,820,RC,,,,outpatient,,,2570,2184.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,246.5,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,235.14,,,,,,,fee schedule,,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,724.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,809.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,724.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,895.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3537.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,3000.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,895.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,478,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,476,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,852.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,235.14,3783,,facility
REMOVE IMPACTED EAR WAX UNI,69209,CPT,450,RC,,,,outpatient,,,230,195.5,826,,,,,,,case rate,,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,69.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,76.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,257.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,76.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,69.62,1548,,facility
THER SPI PNXR DRG CSF,62272,CPT,450,RC,,,,outpatient,,,2390,2031.5,826,,,,,,,case rate,,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,832.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,920.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,3086.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,920.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,876.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,3086.41,,facility
ECHO EXAM OF ABDOMEN,76705,CPT,402,RC,,,,outpatient,,,542,460.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,230.01,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,485.01,,,,,,,fee schedule,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
TX/PRO/DX INJ SAME DRUG ADON,96376,CPT,260,RC,,,,outpatient,,,1014,861.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,3783,,facility
DBRDMT OPN WND 1ST 20 CM/<,97597,CPT,450,RC,,,,outpatient,,,1035,879.75,826,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,236.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,877.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,236.76,1548,,facility
US EXAM OF HEAD AND NECK,76536,CPT,402,RC,,,,outpatient,,,542,460.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,325.95,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,479.67,,,,,,,fee schedule,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
CLTX SHO DSLC W/MNPJ WO ANES,23650,CPT,450,RC,,,,outpatient,,,737,626.45,826,,,,,,,case rate,,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,291.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,321.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1078.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,321.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,291.08,1548,,facility
TREAT HIP DISLOCATION,27257,CPT,450,RC,,,,outpatient,,,5662,4812.7,826,,,,,,,case rate,,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1897.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2097.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,7030.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2097.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,7030.81,,facility
CBT 1ST HOUR,94644,CPT,410,RC,,,,inpatient,,,536,455.6,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
INTMD RPR FACE/MM 5.1-7.5 CM,12053,CPT,450,RC,,,,outpatient,,,886,753.1,826,,,,,,,case rate,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,479.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1777.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,479.71,1777.46,,facility
INSERT TUNNELED CV CATH,36558,CPT,450,RC,,,,outpatient,,,10932,9292.2,826,,,,,,,case rate,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3726.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,13805.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4118.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3922.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,13805.86,,facility
DRAIN/INJ JOINT/BURSA W/O US,20610,CPT,450,RC,,,,outpatient,,,1029,874.65,826,,,,,,,case rate,,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,362.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,400.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1342.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,400.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,381.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,362.22,1548,,facility
AUTOLOGOUS BLOOD OP SALVAGE,86891,CPT,300,RC,,,,outpatient,,,2016,1713.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,531,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,2321.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,2321.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,850.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,950.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,850.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1050.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4153.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,3522.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,1050.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,753.84,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,753.84,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1000.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,531,4153.28,,facility
TRANSFUSION BLD/BLD COMPNT,36430,CPT,391,RC,,,,outpatient,,,1475,1253.75,,70,,561.6,561.6,561.6,1 through 10,percent of total billed charges,,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,772.2,772.2,846.56,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,615.68,615.68,615.68,1 through 10,percent of total billed charges,,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,465.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,520.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,465.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,575.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,37,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,575.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1314,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1538,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,548.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,465.81,3783,,facility
UNLISTED PROCEDURE LIPS,40799,CPT,450,RC,,,,outpatient,,,791,672.35,826,,,,,,,case rate,,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,279.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,308.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1035.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,308.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,294.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,279.5,1548,,facility
UNLISTED PROCEDURE RECTUM,45999,CPT,450,RC,,,,outpatient,,,1776,1509.6,826,,,,,,,case rate,,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1097.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1212.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,4066.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,1212.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,4066.16,,facility
PLATELETS LEUKOCYTES REDUCED,P9031,HCPCS,390,RC,,,,outpatient,,,2980,2533,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,122.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,136.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,122.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,150.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,37,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,150.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1314,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1538,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,143.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,122.02,3783,,facility
BRIEF EMOTIONAL/BEHAV ASSMT,96127,CPT,918,RC,,,,outpatient,,,120,102,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,150,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,155,,,,,,,case rate,,155,,,,,,,case rate,,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,44.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,39.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,192.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,163.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,48.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,363,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,361,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.43,3783,,professional
PREV MED CNSL INDIV APPRX 45,99403,CPT,510,RC,,,,outpatient,,,249,211.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
"ALBUMIN (HUMAN), 25%, 50ML",P9047,HCPCS,636,RC,,,,outpatient,,,371,315.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,45.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,55.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,220.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,55.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52.45,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,52.45,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,53.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45.12,3783,,facility
RBC ANTIBODY ELUTION,86860,CPT,302,RC,,,,outpatient,,,312,265.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,119.61,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,490.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,490.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,179.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,201.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,179.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,222.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,878.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,744.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,222.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,172.2,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,172.2,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,119.61,3783,,facility
COOMBS TEST DIRECT,86880,CPT,302,RC,,,,outpatient,,,267,226.95,,70,,8,8,8,1 through 10,percent of total billed charges,,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22.35,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,170.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,170.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,29.97,29.97,29.97,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,18.69,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.39,,,,,,,fee schedule,,69.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,5.39,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,76.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,304.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,257.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,76.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.47,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.47,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.39,3783,,facility
RBC ANTIBODY IDENTIFICATION,86870,CPT,302,RC,,,,outpatient,,,860,731,,70,,39,39,39,1 through 10,percent of total billed charges,,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,164.31,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1032.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,1032.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,59.95,59.95,59.95,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,32.51,32.51,32.51,1 through 10,percent of total billed charges,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,378.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,422.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,378.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,467.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1847.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1567.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,467.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,340.09,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,340.09,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,164.31,3783,,facility
DRAINAGE OF FINGER ABSCESS,26010,CPT,450,RC,,,,outpatient,,,536,455.6,826,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,236.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,877.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,236.76,1548,,facility
DRAINAGE OF MOUTH LESION,41000,CPT,450,RC,,,,outpatient,,,3234,2748.9,826,,,,,,,case rate,,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,636.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,703.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,2358.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,703.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,669.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,636.44,2358.19,,facility
APPLY FOREARM SPLINT,29126,CPT,450,RC,,,,outpatient,,,218,185.3,826,,,,,,,case rate,,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,157.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,581.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,157.01,1548,,facility
FACTOR VIII,J7190,HCPCS,636,RC,,,,outpatient,,,13,11.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,0.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1.11,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1.11,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,0.94,3783,,facility
BLOOD TYPING RBC ANTIGENS,86905,CPT,300,RC,,,,outpatient,,,896,761.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.78,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1032.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,1032.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13.29,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.83,,,,,,,fee schedule,,422.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,3.83,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,467.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1847.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1567.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,467.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.6,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4.6,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,445.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.83,3783,,facility
RBC ANTIBODY SCREEN,86850,CPT,302,RC,,,,outpatient,,,588,499.8,,70,,18,18,18,71,percent of total billed charges,,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.49,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,150.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,150.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,7.29,7.29,7.29,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,59.95,5.61,133.67,206,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27.45,,,,,,,fee schedule,,,85,,20.59,10.68,27.45,1 through 10,percent of total billed charges,,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.77,,,,,,,fee schedule,,61.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,9.77,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,7.01,5.55,74.94,109,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.55,5.55,54.5,342,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,58.34,6,64.17,14,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,59.95,59.95,59.95,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,67.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,134.89,12.62,134.89,25,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,55.74,5.61,59.95,105,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,117.18,7.16,128.89,81,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,227.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,67.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.72,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11.72,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.77,3783,,facility
PACKED CELLS BB/PL,02106331,CDM,390,RC,,,,outpatient,,,641,544.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,37,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1314,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1538,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1314,3783,,facility
COOMBS TEST INDIRECT TITER,86886,CPT,302,RC,,,,outpatient,,,541,459.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.03,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,490.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,490.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17.96,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.18,,,,,,,fee schedule,,201.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,5.18,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,222.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,5.78,5.78,5.78,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,878.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,744.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,222.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.22,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.22,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,211.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.18,3783,,facility
CLTX DST RDL FX/EPHYS SEP W/,25605,CPT,450,RC,,,,outpatient,,,5012,4260.2,826,,,,,,,case rate,,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1897.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2097.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,7030.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2097.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,7030.81,,facility
SC THER INFUSION RESET PUMP,96371,CPT,260,RC,,,,outpatient,,,243,206.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,76.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,84.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,76.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,366.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,311.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,93.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,89.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,76.02,3783,,facility
OB US < 14 WKS SINGLE FETUS,76801,CPT,402,RC,,,,outpatient,,,979,832.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,269.46,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,549.78,,,,,,,fee schedule,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
CLTX SCAP FX W/MNPJ +-TRACTJ,23575,CPT,450,RC,,,,outpatient,,,3935,3344.75,826,,,,,,,case rate,,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1897.52,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2097.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,7030.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2097.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1997.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,7030.81,,facility
SERVICE FEE NYBB SURCHARGE,02106222,CDM,380,RC,,,,outpatient,,,449,381.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,55,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,37,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1314,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1538,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1314,3783,,facility
MICROBE SUSCEPTIBLE MIC,87186,CPT,300,RC,,,,outpatient,,,24,20.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.49,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,20.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,20.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,24,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.65,,,,,,,fee schedule,,8.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,8.65,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,30.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,9.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.38,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10.38,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.22,3783,,facility
RED BLOOD CELLS UNIT,P9021,HCPCS,390,RC,,,,outpatient,,,1155,981.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,127.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,142.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,127.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,157.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,37,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,157.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1314,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1538,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,149.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,127.36,3783,,facility
VISUAL ACUITY SCREEN,99173,CPT,450,RC,,,,outpatient,,,1014,861.9,826,,,,,,,case rate,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,813,1548,,facility
AEROSOL INHALATION TREATMENT,94642,CPT,410,RC,,,,inpatient,,,665,565.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
PER PM REEVAL EST PAT 65+ YR,99397,CPT,510,RC,,,,outpatient,,,619,526.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
PERQ TESTS W/ALRGNC XTRCS,95004,CPT,924,RC,,,,outpatient,,,1844,1567.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28.5,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,2858.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,2709.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,19.08,,,,,,,fee schedule,,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,906.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,1013.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,906.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1120.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4426.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,3754.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,1120.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,230,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,229,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1066.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19.08,4426.8,,facility
TREAT HAND DISLOCATION,26670,CPT,450,RC,,,,outpatient,,,901,765.85,826,,,,,,,case rate,,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,291.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,321.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1078.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,321.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,291.08,1548,,facility
TRANSVAGINAL US NON-OB,76830,CPT,402,RC,,,,outpatient,,,894,759.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,328.59,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,501.64,,,,,,,fee schedule,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,3783,,facility
RBC LEUKOCYTES REDUCED,P9016,HCPCS,390,RC,,,,outpatient,,,2025,1721.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,156.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,174.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,156.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,193.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,37,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,193.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1314,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1538,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,156.4,3783,,facility
PLASMA 1 DONOR FRZ W/IN 8 HR,P9017,HCPCS,390,RC,,,,outpatient,,,509,432.65,,70,,193.6,193.6,193.6,1 through 10,percent of total billed charges,,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,72.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,81.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,72.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,89.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,37,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,89.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1314,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1538,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,85.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,72.73,3783,,facility
APHERESIS IMMUNOADS SLCTV,36516,CPT,940,RC,,,,outpatient,,,13762,11697.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,304.13,,,,,,,fee schedule,,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4598.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,5139.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,4598.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5680.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,22452.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,19044.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,5680.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1037,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5410.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,304.13,22452.58,,facility
MICROBE SUSCEPT MACROBROTH,87188,CPT,300,RC,,,,outpatient,,,18,15.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.28,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,15.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,15.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.64,,,,,,,fee schedule,,6.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,6.64,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,23.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,6.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.97,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,7.97,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.31,3783,,facility
REPLACE G/C TUBE PERC,49450,CPT,450,RC,,,,outpatient,,,1964,1669.4,826,,,,,,,case rate,,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1070.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1182.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,3965.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,1182.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1126.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,3965.74,,facility
REMOVE FOREIGN BODY FROM EYE,65222,CPT,450,RC,,,,outpatient,,,405,344.25,826,,,,,,,case rate,,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,157.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,581.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,157.01,1548,,facility
EXCISION OF NAIL FOLD TOE,11765,CPT,450,RC,,,,outpatient,,,1292,1098.2,826,,,,,,,case rate,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,479.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1777.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,479.71,1777.46,,facility
"PLATELETS, PHERESIS",P9034,HCPCS,390,RC,,,,outpatient,,,4520,3842,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,261.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,292.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,261.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,322.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,37,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,322.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1314,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1538,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,307.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,261.33,3783,,facility
INTMD RPR N-HF/GENIT 2.5CM/<,12041,CPT,450,RC,,,,outpatient,,,756,642.6,826,,,,,,,case rate,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,479.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1777.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,479.71,1777.46,,facility
TREAT ELBOW DISLOCATION,24640,CPT,450,RC,,,,outpatient,,,545,463.25,826,,,,,,,case rate,,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,291.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,321.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1078.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,321.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,291.08,1548,,facility
CMPLX RPR E/N/E/L 1.1-2.5 CM,13151,CPT,450,RC,,,,outpatient,,,1726,1467.1,826,,,,,,,case rate,,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,872.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,963.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,3231.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,963.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,918.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,3231.54,,facility
COLPOTOMY W/EXPLORATION,57000,CPT,450,RC,,,,outpatient,,,7388,6279.8,826,,,,,,,case rate,,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3820,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4222.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,14154.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4222.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4021.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,14154.1,,facility
CLTX ACROMCLAV DISLC W/MNPJ,23545,CPT,450,RC,,,,outpatient,,,860,731,826,,,,,,,case rate,,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,291.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,321.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1078.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,321.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,291.08,1548,,facility
PRCRD DRG 0-5YR OR W/ANOMLY,33018,CPT,450,RC,,,,outpatient,,,1205,1024.25,826,,,,,,,case rate,,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8512,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,290.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,320.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1074.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,320.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,305.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,290.11,8512,,facility
REMOVE NASAL FOREIGN BODY,30300,CPT,450,RC,,,,outpatient,,,640,544,826,,,,,,,case rate,,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,157.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,581.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,157.01,1548,,facility
SURG SERV IN ULTRASOUND,04120282,CDM,450,RC,,,,outpatient,,,1490,1266.5,826,,,,,,,case rate,,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",813,1548,,facility
TREAT ELBOW DISLOCATION,24600,CPT,450,RC,,,,outpatient,,,813,691.05,826,,,,,,,case rate,,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,291.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,321.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1078.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,321.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,306.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,291.08,1548,,facility
REMOVAL OF NAIL BED,11750,CPT,450,RC,,,,outpatient,,,1922,1633.7,826,,,,,,,case rate,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,479.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1777.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,479.71,1777.46,,facility
SYNCH AUDIO-VIDEO EST LOW 20,98005,CPT,510,RC,,,,outpatient,,,171,145.35,,70,,192.5,192.5,192.5,1 through 10,percent of total billed charges,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,149.85,136.78,155.99,16,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,337.16,337.16,337.16,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,380.99,149.85,380.99,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
OFFICE O/P NEW HI 60 MIN,99205,CPT,510,RC,,,,outpatient,,,907,770.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,467.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,156.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,174.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,156.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,204.55,204.55,204.55,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,193.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,763.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,647.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,193.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,184.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,3783,,facility
INSJ PICC 5 YR+ W/O IMAGING,36569,CPT,450,RC,,,,outpatient,,,4086,3473.1,826,,,,,,,case rate,,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1857.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2053.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,6882.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2053.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1955.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,6882.87,,facility
RPR S/N/AX/GEN/TRNK 2.5CM/<,12001,CPT,450,RC,,,,outpatient,,,597,507.45,826,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,1221.62,1221.62,1221.62,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,236.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,542.94,542.94,542.94,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,596,596,596,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,596,542.94,596,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,877.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,236.76,1548,,facility
RPR F/E/E/N/L/M 7.6-12.5 CM,12015,CPT,450,RC,,,,outpatient,,,359,305.15,826,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,236.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,877.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,236.76,1548,,facility
RPR S/N/AX/GEN/TRNK2.6-7.5CM,12002,CPT,450,RC,,,,outpatient,,,689,585.65,826,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,1341,1341,1341,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,1221.62,1221.62,1341,18,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,236.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,542.94,542.94,542.94,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,596,596,823.94,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,1167.32,1167.32,1167.32,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,877.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,236.76,1548,,facility
"SURGICAL SERV,IN RADIOLOGY",04120298,CDM,450,RC,,,,outpatient,,,1490,1266.5,826,,,,,,,case rate,,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",813,1548,,facility
EVABB,02081029,CDM,510,RC,,,,outpatient,,,12,10.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,135,3783,,facility
BEHAV CHNG SMOKING > 10 MIN,99407,CPT,510,RC,,,,outpatient,,,162,137.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,118.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,44.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,39.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,193.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,163.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,48.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.56,3783,,facility
AUDIT/DAST OVER 30 MIN,99409,CPT,510,RC,,,,outpatient,,,413,351.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,60.87,60.87,60.87,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
NSL/SINS NDSC SRG NSL HEMRRG,31238,CPT,450,RC,,,,outpatient,,,5291,4497.35,826,,,,,,,case rate,,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2100.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2321.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,7782.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,2321.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2210.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,7782.47,,facility
OFFICE O/P EST HI 40 MIN,99215,CPT,510,RC,,,,outpatient,,,907,770.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,361.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,120.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,135.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,120.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,149.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,590.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,500.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,149.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,142.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,120.97,3783,,facility
TTE F-UP OR LMTD,93308,CPT,480,RC,,,,outpatient,,,1227,1042.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,533.55,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,794.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,752.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,206.53,206.53,206.53,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,929.39,844.9,929.39,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,871.21,,,,,,,fee schedule,,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,251.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,281.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,251.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,425.33,425.33,425.33,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,442.14,442.14,442.14,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,311.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,425.33,425.33,425.33,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1229.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,833.73,833.73,833.73,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,1043.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,311.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1037,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,251.92,3783,,facility
OPH US DX B-SCAN,76512,CPT,402,RC,,,,outpatient,,,894,759.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,80.16,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,355.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,383.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,529.66,,,,,,,fee schedule,,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,123.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,110.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,538.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,457.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,136.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,174.35,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,129.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,80.16,3783,,facility
UNLISTED PROCEDURE ANUS,46999,CPT,450,RC,,,,outpatient,,,1865,1585.25,826,,,,,,,case rate,,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1419,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1538,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,886,,,,,,,case rate,,966,,,,,,,case rate,,813,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1548,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1322,,,,,,,case rate,,1090,,,,,,,case rate,,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1097.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1212.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1196,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,4066.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,1212.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1349,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1155.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,813,4066.16,,facility
UNLISTED PULMONARY SVC/PX,94799,CPT,410,RC,,,,inpatient,,,685,582.25,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
WOUND(S) CARE NON-SELECTIVE,97602,CPT,510,RC,,,,outpatient,,,459,390.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,633.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,211.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,236.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,211.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1034.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,877.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,3783,,facility
IMMUNIZATION ADMIN EACH ADD,90472,CPT,771,RC,,,,outpatient,,,174,147.9,,70,,8,8,8,1 through 10,percent of total billed charges,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",54.43,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,39.42,39.42,39.42,1 through 10,percent of total billed charges,,,,"Payer contract is 254.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,42.35,,,,,,,fee schedule,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,165,165,165,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,25.07,25.07,25.07,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,11.14,11.14,11.14,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",11.14,11.14,11.14,14,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",42.35,3783,,facility
INIT PM E/M NEW PAT INFANT,99381,CPT,510,RC,,,,outpatient,,,363,308.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
HYDRATE IV INFUSION ADD-ON,96361,CPT,260,RC,,,,outpatient,,,174,147.9,,70,,20,20,20,1 through 10,percent of total billed charges,,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,341.53,310.48,353.8,36,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,55.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,49.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,591.48,591.48,603.75,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,238.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 410.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,693.91,693.91,693.91,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,202.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 348.00,61.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,58.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,49.44,3783,,facility
IV PUMP,01601001,CDM,260,RC,,,,outpatient,,,124,105.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 410.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 348.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,3783,,facility
OFF/OP CNSLTJ NEW/EST LOW 30,99243,CPT,510,RC,,,,outpatient,,,709,602.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
RPR S/N/AX/GEN/TRK7.6-12.5CM,12004,CPT,510,RC,,,,outpatient,,,909,772.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,633.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,211.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,236.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,211.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1034.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,877.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,3783,,facility
INIT PM E/M NEW PAT 65+ YRS,99387,CPT,510,RC,,,,outpatient,,,363,308.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
FETAL NON-STRESS TEST,59025,CPT,514,RC,,,,outpatient,,,656,557.6,,70,,12,12,12,1 through 10,percent of total billed charges,,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,637.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,287.72,287.72,287.72,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,213.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,238.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,213.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,359.65,359.65,359.65,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,287.72,262.12,287.72,12,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,263.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,647.37,647.37,647.37,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1042.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,883.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,263.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,3783,,facility
ADM SARSCV2 BVL 50MCG/.5ML A,0134A,CPT,771,RC,,,,outpatient,,,126,107.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,55,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",55,3783,,facility
PRENATAL FOLLOW-UP-LEVEL 3,05601034,CDM,510,RC,,,,outpatient,,,276,234.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,3783,,facility
UNLISTED PX MAT CARE&DLVR,59899,CPT,510,RC,,,,outpatient,,,671,570.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,637.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,213.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,238.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,213.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,263.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1042.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,883.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,263.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,251.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,3783,,facility
PRENATAL FOLLOW-UP-LEVEL 2,05601033,CDM,510,RC,,,,outpatient,,,235,199.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,3783,,facility
INTRM OPH EXAM NEW PATIENT,92002,CPT,510,RC,,,,outpatient,,,556,472.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,420.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,140.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,157.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,140.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,173.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,686.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,582.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,173.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,3783,,facility
ASSAY OF PROTEIN OTHER,84157,CPT,301,RC,,,,outpatient,,,40,34,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.46,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,9.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,9.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12.73,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4,,,,,,,fee schedule,,3.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,4,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,14.08,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.8,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4.8,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.8,3783,,facility
PAPPA SERUM,84163,CPT,301,RC,,,,outpatient,,,314,266.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60.45,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,34.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,34.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52.24,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.05,,,,,,,fee schedule,,14.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,15.05,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,52.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,15.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.06,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18.06,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.3,3783,,facility
EDU&TRN PT SELF-MGMT NQHP 1,98960,CPT,942,RC,,,,outpatient,,,487,413.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",148.12,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",156,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,154,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",148.12,3783,,facility
PREV VISIT EST AGE 40-64,99396,CPT,510,RC,,,,outpatient,,,619,526.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
ACUPUNCTURE REHAB INIT VISIT,03299342,CDM,510,RC,,,,outpatient,,,95,80.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 254.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge associated HCPCS and/or revenue code is invalid and therefore, not paid under Medicare OPPS payment. + No services performed during 15-month lookback period",135,3783,,facility
ALCOHOL/DRUG SERVICE 15 MIN,H0050,HCPCS,944,RC,,,,outpatient,,,172,146.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,227,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,226,,,,,,,case rate,,227,,,,,,,case rate,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,226,3783,,facility
AUDIT/DAST 15-30 MIN,99408,CPT,510,RC,,,,outpatient,,,647,549.95,,70,,40,40,40,1 through 10,percent of total billed charges,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,60.87,60.87,60.87,17,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,59.24,59.24,65.75,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
RPR S/N/AX/GEN/TRNK >30.0 CM,12007,CPT,490,RC,,,,outpatient,,,1622,1378.7,1648,,,,,,,fee schedule,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3370,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,211.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,236.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,211.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1034.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,877.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,261.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3229,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,249.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,211.84,3783,,facility
COLD AGGLUTININ TITER,86157,CPT,302,RC,,,,outpatient,,,200,170,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32.85,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,18.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,18.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,27.96,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.06,,,,,,,fee schedule,,7.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,8.06,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,28.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,8.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.66,3783,,facility
ASSAY PH BODY FLUID NOS,83986,CPT,301,RC,,,,outpatient,,,156,132.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.46,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,8.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,8.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12.42,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.58,,,,,,,fee schedule,,3.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,3.58,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,3.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.3,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4.3,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.4,3783,,facility
ASSAY BLOOD CARBON DIOXIDE,82374,CPT,301,RC,,,,outpatient,,,92,78.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19.71,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,11.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,11.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16.94,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.88,,,,,,,fee schedule,,4.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,4.88,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,17.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,5.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.86,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.86,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.88,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.64,3783,,facility
OB PE SFLT-1/PLGF IA SRM/PLS,0524U,CPT,300,RC,,,,outpatient,,,315,267.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,298.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,298.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,122.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,135.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,534.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,453.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,135.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,128.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,122.38,3783,,facility
ASSAY OF PROINSULIN,84206,CPT,301,RC,,,,outpatient,,,101,85.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,97.26,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,61.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,61.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,75,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.69,,,,,,,fee schedule,,25.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,26.69,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,110.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,93.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,28.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32.03,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32.03,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,26.69,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,25.36,3783,,facility
ASSAY OF BLOOD LIPOPROTEIN,83721,CPT,301,RC,,,,outpatient,,,111,94.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,38.13,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,24.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,24.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,33.1,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.5,,,,,,,fee schedule,,9.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,10.5,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,11.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,43.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,36.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,11.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.6,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12.6,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.98,3783,,facility
HEPATITIS B SURFACE AG IA,87340,CPT,300,RC,,,,outpatient,,,30,25.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.06,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,23.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,23.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.33,,,,,,,fee schedule,,9.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,10.33,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,10.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,42.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,36.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,10.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.4,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12.4,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.81,3783,,facility
EVAA9,02081031,CDM,510,RC,,,,outpatient,,,819,696.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not Medicare Reimbursable + No services performed during 15-month lookback period,135,3783,,facility
PREV VISIT EST AGE 5-11,99393,CPT,510,RC,,,,outpatient,,,363,308.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
BEHAV CHNG SMOKING 3-10 MIN,99406,CPT,510,RC,,,,outpatient,,,162,137.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,118.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,44.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,39.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,48.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,124.52,124.52,124.52,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,280.34,61.43,280.34,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,193.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,163.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,48.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,46.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,39.56,3783,,facility
HPV VACCINE,04705144,CDM,250,RC,,,,inpatient,,,749,636.65,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
GTT-ADDED SAMPLES,82952,CPT,301,RC,,,,outpatient,,,413,351.05,,70,,4,4,4,1 through 10,percent of total billed charges,,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.78,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,9.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,9.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,1.41,1.41,1.41,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13.6,,,,,,,fee schedule,,,85,,10.2,10.2,10.2,1 through 10,percent of total billed charges,,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.92,,,,,,,fee schedule,,3.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,3.92,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,1.4,1.4,1.75,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,1.4,1.4,1.41,34,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,13.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4.12,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.7,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4.7,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.72,3783,,facility
ASSAY OF URINE/UREA-N,84540,CPT,301,RC,,,,outpatient,,,155,131.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19.71,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,12.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,12.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16.47,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.56,,,,,,,fee schedule,,5.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,5.56,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,19.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,5.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.28,3783,,facility
ASSAY OF TOTAL THYROXINE,84436,CPT,301,RC,,,,outpatient,,,86,73.1,,70,,10,10,10,49,percent of total billed charges,,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27.6,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,15.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,15.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,7.49,7.49,23.83,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.76,5.76,5.76,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,23.83,,,,,,,fee schedule,,,85,,23.83,17.87,23.83,15,percent of total billed charges,,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.87,,,,,,,fee schedule,,6.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,6.87,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,7.13,5.7,7.13,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.7,5.7,5.76,57,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,6.17,6.17,6.17,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,7.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,12.96,12.96,12.96,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,5.76,5.76,5.76,18,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,28.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,24.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,7.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.24,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.24,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,6.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.53,3783,,facility
BICILLIN LA,04705154,CDM,250,RC,,,,inpatient,,,1041,884.85,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
HRDTRY PERPH NEURPHY PANEL,81448,CPT,300,RC,,,,outpatient,,,1628,1383.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2367.21,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1356.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,1356.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,584.9,,,,,,,fee schedule,,555.66,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,584.9,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,614.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2427.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,2058.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,614.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,701.88,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,701.88,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,584.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,555.66,3783,,facility
OFFICE O/P NEW MOD 45 MIN,99204,CPT,510,RC,,,,outpatient,,,847,719.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,339.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,113.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,126.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,113.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,165.57,165.57,165.57,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,164.35,164.35,164.35,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,140.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,157.41,157.41,157.41,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,554.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,469.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,140.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,133.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,113.47,3783,,facility
BENZODIAZEPINES 13 OR MORE,80347,CPT,301,RC,,,,outpatient,,,336,285.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
ASSAY OF SERUM ALBUMIN,82040,CPT,301,RC,,,,outpatient,,,92,78.2,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19.71,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,11.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,11.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17.17,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.95,,,,,,,fee schedule,,4.7,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,4.95,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,5.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,17.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,5.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.94,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.94,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.7,3783,,facility
HIV-1ANTIBODY,86701,CPT,302,RC,,,,outpatient,,,143,121.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.49,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,20.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,20.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30.83,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.89,,,,,,,fee schedule,,8.45,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,8.89,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,31.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,9.33,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.45,3783,,facility
ASSAY OF TOBRAMYCIN,80200,CPT,301,RC,,,,outpatient,,,398,338.3,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,65.73,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,37.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,37.42,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,55.95,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16.13,,,,,,,fee schedule,,15.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,16.13,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,66.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,56.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,16.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19.36,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,19.36,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,16.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.32,3783,,facility
PMP22 GENE DUP/DELET,81324,CPT,300,RC,,,,outpatient,,,2111,1794.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2761.53,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1759.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,1759.4,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,758.36,,,,,,,fee schedule,,720.44,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,758.36,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,796.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3147.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,2669.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,796.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,910.03,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,910.03,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,758.36,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,720.44,3783,,facility
DRUG SCREEN QUANT ZONISAMIDE,80203,CPT,301,RC,,,,outpatient,,,179,152.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53.88,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,30.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,30.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,45.97,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.25,,,,,,,fee schedule,,12.59,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,13.25,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,54.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,46.64,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,13.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.9,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.9,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.59,3783,,facility
ASSAY OF LIPOPROTEIN,83718,CPT,301,RC,,,,outpatient,,,171,145.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32.85,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28.44,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.19,,,,,,,fee schedule,,7.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,8.19,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,28.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,8.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.83,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9.83,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.78,3783,,facility
ALCHOHOL/DRUG; AMBUL DETOX,H0014,HCPCS,911,RC,,,,outpatient,,,277,235.45,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,196.6,196.6,201.71,16,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,263,263,263,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,202.69,202.69,202.69,12,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,professional
EXTENDED VISUAL FIELD XM,92083,CPT,519,RC,,,,outpatient,,,585,497.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,419.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,157.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,685.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,581.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,3783,,facility
AMPHETAMINES 3OR 4,80325,CPT,300,RC,,,,outpatient,,,320,272,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 232.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,3783,,facility
TTE W/DOPPLER COMPLETE,93306,CPT,483,RC,,,,outpatient,,,2774,2357.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1819.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1724,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1888.15,,,,,,,fee schedule,,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,576.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,644.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,576.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,712.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2816.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,2389.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,712.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,664,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,660,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,576.93,3783,,facility
ASSAY OF URINE POTASSIUM,84133,CPT,301,RC,,,,outpatient,,,145,123.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.1,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,10.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,10.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14.95,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.73,,,,,,,fee schedule,,4.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,4.73,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,4.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,19.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,16.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,4.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.68,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,4.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.49,3783,,facility
ASSAY OF URINE CHLORIDE,82436,CPT,301,RC,,,,outpatient,,,145,123.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.03,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,13.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,13.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17.45,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.75,,,,,,,fee schedule,,5.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,5.75,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,20.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,6.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.9,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.9,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.46,3783,,facility
COMPREHEN METABOLIC PANEL,80053,CPT,301,RC,,,,outpatient,,,328,278.8,,70,,12,12,12,754,percent of total billed charges,,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,43.38,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,24.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,24.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,10.1,10.1,36.64,17,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,26.08,10.1,58.68,693,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,22.73,22.73,58.68,35,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,36.64,,,,,,,fee schedule,,,85,,36.64,19.55,36.64,145,percent of total billed charges,,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.56,,,,,,,fee schedule,,10.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,10.56,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,12.5,10,32.6,295,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,10.1,10,26.08,950,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,27.92,27.92,34.43,78,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,26.08,26.08,26.08,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,11.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,58.68,22.73,58.68,82,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,58.68,58.68,58.68,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,26.08,10.1,26.08,480,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,43.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,26.08,21.72,56.07,668,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,37.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,11.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12.67,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,10.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.03,3783,,facility
ASSAY OF URINE PHOSPHORUS,84105,CPT,301,RC,,,,outpatient,,,145,123.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,21.03,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,13.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,13.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,17.96,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.78,,,,,,,fee schedule,,5.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,5.78,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,6.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,23.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,20.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,6.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6.94,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,6.94,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,5.78,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5.49,3783,,facility
TTE W/O DOPPLER COMPLETE,93307,CPT,483,RC,,,,outpatient,,,1346,1144.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1049.12,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,794.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,752.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1346,,,,,,,fee schedule,,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,251.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,281.56,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,251.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,311.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1229.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1043.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,311.2,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,664,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,660,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,296.38,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,251.92,3783,,facility
CARDIOVASCULAR STRESS TEST,93015,CPT,482,RC,,,,outpatient,,,1789,1520.65,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,451.75,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,,Payer contract is 268.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 268.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,237.61,,,,,,,fee schedule,,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1037,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,237.61,3783,,facility
XTRNL ECG REC<48 HRS REC,93225,CPT,731,RC,,,,outpatient,,,1533,1303.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,220.29,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,442.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,419.79,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,92.36,,,,,,,fee schedule,,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,157.01,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,140.48,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,685.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,581.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,173.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,312,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,312,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,165.27,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,92.36,3783,,facility
XTRNL ECG REC<48 HR SCAN A/R,93226,CPT,731,RC,,,,outpatient,,,585,497.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,388.75,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,196.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,186.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,131.4,,,,,,,fee schedule,,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,69.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,62.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,76.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,304.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,257.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,76.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,312,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,312,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,73.28,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.29,3783,,facility
REMOVAL OF HEMORRHOID CLOT,46320,CPT,361,RC,,,,outpatient,,,8654,7355.9,1648,,,,,,,fee schedule,,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2086,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3795,,,,,,,fee schedule,,3795,,,,,,,fee schedule,,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1412.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1560.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,6168.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,5232.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,1560.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,5048,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,5048,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1486.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1412.11,6168.68,,facility
LIPID PANEL,80061,CPT,301,RC,,,,outpatient,,,119,101.15,,70,,19,19,19,520,percent of total billed charges,,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53.88,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,31.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,31.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,7.93,7.93,46.45,16,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,6.1,6.1,13.73,94,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,13.73,13.73,13.73,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,46.45,,,,,,,fee schedule,,,85,,46.45,22.09,46.45,189,percent of total billed charges,,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.39,,,,,,,fee schedule,,12.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,13.39,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,7.55,6.04,7.63,85,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,6.04,6.04,13.04,328,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,13.96,13.96,13.96,17,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,14.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,13.73,13.73,29.34,14,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,6.1,6.1,13.04,78,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,13.12,13.12,28.04,197,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,47.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,14.06,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,16.07,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,16.07,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,13.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.72,3783,,facility
HOT OR COLD PACKS THERAPY,97010,CPT,420,RC,,,,outpatient,,,271,230.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,207,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,,Payer contract is 268.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 268.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,207,,,,,,,case rate,,174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,175,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,148,,,,,,,case rate,,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,171,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,169,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,148,3783,,facility
MANUAL THERAPY 1/> REGIONS,97140,CPT,420,RC,,,,outpatient,,,271,230.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,207,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,84.13,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,207,,,,,,,case rate,,174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,90.12,,,,,,,fee schedule,,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,29.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,26.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,32.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,175,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,148,,,,,,,case rate,,32.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,171,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,169,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,31.39,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,26.68,3783,,facility
THERAPEUTIC EXERCISES,97110,CPT,420,RC,,,,outpatient,,,651,553.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,207,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,88.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,207,,,,,,,case rate,,174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,100.49,,,,,,,fee schedule,,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,31.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,27.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,34.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,175,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,148,,,,,,,case rate,,34.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,171,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,169,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,32.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,27.96,3783,,facility
ASSAY OF LACTIC ACID,83605,CPT,301,RC,,,,outpatient,,,241,204.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,43.38,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,26.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,26.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37.06,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.57,,,,,,,fee schedule,,10.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,11.57,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,48.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,40.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,12.15,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.88,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,13.88,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,11.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.99,3783,,facility
ASSAY OF AMMONIA,82140,CPT,301,RC,,,,outpatient,,,319,271.15,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,59.16,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,33.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,33.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,50.55,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.57,,,,,,,fee schedule,,13.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,14.57,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60.47,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,51.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,17.48,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,17.48,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,14.57,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,13.84,3783,,facility
ASSAY OF PROTEIN SERUM,84155,CPT,301,RC,,,,outpatient,,,54,45.9,,70,,6,6,6,1 through 10,percent of total billed charges,,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.46,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,8.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,8.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,12.73,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.67,,,,,,,fee schedule,,3.49,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,3.67,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,4.59,4.59,4.59,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,4.59,4.59,4.59,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,3.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,12.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,3.85,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4.4,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4.4,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,3.67,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3.49,3783,,facility
HEPATIC FUNCTION PANEL,80076,CPT,301,RC,,,,outpatient,,,193,164.05,,70,,11,11,11,56,percent of total billed charges,,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,32.85,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,18.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,18.95,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,20.77,20.77,20.77,1 through 10,percent of total billed charges,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,9.52,9.52,9.52,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,7.32,7.32,7.32,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,28.35,,,,,,,fee schedule,,,85,,28.35,21.26,28.35,1 through 10,percent of total billed charges,,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.17,,,,,,,fee schedule,,7.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,8.17,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,9.06,7.25,16.3,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,7.32,7.25,9.06,18,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,7.84,7.84,13.96,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,8.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,16.47,16.47,16.47,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,7.32,7.32,7.32,22,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,33.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,15.74,15.74,15.74,17,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,28.76,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,8.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,9.8,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,9.8,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.17,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.76,3783,,facility
ASSAY OF FETAL FIBRONECTIN,82731,CPT,301,RC,,,,outpatient,,,510,433.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,260.25,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,149.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,149.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,223.45,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64.41,,,,,,,fee schedule,,61.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,64.41,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,67.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,267.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,226.72,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,67.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,77.29,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,77.29,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,64.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,61.19,3783,,facility
NRV CNDJ TST 5-6 STUDIES,95909,CPT,922,RC,,,,outpatient,,,1090,926.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,718.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,681.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,505.69,,,,,,,fee schedule,,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,254.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1113.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,944.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,218,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217,3783,,facility
NRV CNDJ TEST 11-12 STUDIES,95912,CPT,922,RC,,,,outpatient,,,1814,1541.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,1242.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1177.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,877.28,,,,,,,fee schedule,,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,394,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,440.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,394,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,486.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1923.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1631.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,486.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,218,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,217,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,217,3783,,facility
"INJ, CABOTE RILPIVIR 2MG 3MG",J0741,HCPCS,636,RC,,,,outpatient,,,18876,16044.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,55,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,20.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,25.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,100.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,25.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.56,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,20.56,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,24.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,20.54,3783,,facility
OFF/OP EST MAY X REQ PHY/QHP,99211,CPT,510,RC,,,,outpatient,,,340,289,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,21.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,8.18,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,7.32,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,45.45,20.2,245.2,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.73,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,30.31,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,9.04,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.61,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,7.32,3783,,facility
VASCULAR FLOW IMAGING,78445,CPT,341,RC,,,,outpatient,,,1294,1099.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2648,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1360.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,1464.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1270.37,,,,,,,fee schedule,,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,422.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,471.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,422.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,521.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2060.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1747.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,521.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,603.39,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,603.39,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,422.09,3783,,facility
RP LOCLZJ TUM 2+AREA 1+D IMG,78801,CPT,341,RC,,,,outpatient,,,3211,2729.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2648,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1360.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,1464.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1315.36,,,,,,,fee schedule,,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,422.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,471.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,422.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,521.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2060.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1747.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,521.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,603.39,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,603.39,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,422.09,3783,,facility
TESTICULAR IMAGING W/FLOW,78761,CPT,341,RC,,,,outpatient,,,2100,1785,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2648,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1360.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,1464.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1304.51,,,,,,,fee schedule,,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,422.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,471.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,422.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,521.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2060.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1747.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,521.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,603.39,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,603.39,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,422.09,3783,,facility
PNXR ASPIR ABSC HMTMA BULLA,10160,CPT,510,RC,,,,outpatient,,,1256,1067.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,1282.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,429.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,479.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,429.22,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2095.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1777.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,530.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,504.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135,3783,,facility
PER PM REEVAL EST PAT INFANT,99391,CPT,510,RC,,,,outpatient,,,363,308.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
AFTER CATARACT LASER SURGERY,66821,CPT,361,RC,,,,outpatient,,,2804,2383.4,1648,,,,,,,fee schedule,,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3370,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,3701,,,,,,,case rate,,3770,,,,,,,case rate,,3174,,,,,,,case rate,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,649.03,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,717.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2835.24,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,2404.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,717.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,4051,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,683.19,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,649.03,4051,,facility
TC99M PERTECHNETATE,A9512,HCPCS,343,RC,,,,outpatient,,,67,56.95,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,59.43,,,,,,,fee schedule,,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",59.43,3783,,facility
TC99M DISOFENIN,A9510,HCPCS,343,RC,,,,outpatient,,,266,226.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
WITHDRAWAL OF ARTERIAL BLOOD,36600,CPT,410,RC,,,,inpatient,,,423,359.55,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,37.03,37.03,40.73,20,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
STRESS TTE COMPLETE,93351,CPT,482,RC,,,,outpatient,,,2384,2026.4,,70,,194,194,194,1 through 10,percent of total billed charges,,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,1816,1816,1816,1 through 10,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1819.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1724,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,322.7,322.7,322.7,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,1929.29,,,,,,,fee schedule,,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,576.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,644.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,576.93,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,143.42,143.42,179.28,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,153.52,153.52,153.52,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,712.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,322.7,322.7,322.7,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,143.42,143.42,143.42,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2816.77,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,308.35,308.35,308.35,14,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,2389.16,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,712.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1042,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1037,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,678.74,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,576.93,3783,,facility
THERA-BAND BLACK PER YARD,05203258,CDM,270,RC,,,,outpatient,,,26,22.1,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CHORIONIC GONADOTROPIN TEST,84702,CPT,301,RC,,,,outpatient,,,336,285.6,,70,,21,21,21,60,percent of total billed charges,,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,60.45,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,34.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,34.92,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,16.24,16.24,16.24,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,12.49,12.49,12.49,13,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,52.24,,,,,,,fee schedule,,,85,,52.24,39.18,52.24,12,percent of total billed charges,,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.05,,,,,,,fee schedule,,14.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,15.05,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,15.46,12.37,15.46,54,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,12.37,12.37,12.37,83,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,27.27,13.64,27.27,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,15.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,28.1,28.1,28.1,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,12.49,12.49,12.49,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,62.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,26.85,15.95,26.85,46,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,52.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,15.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.06,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18.06,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.05,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.3,3783,,facility
ALCOHOL/DRUG; CASE MGMNT,H0006,HCPCS,510,RC,,,,outpatient,,,356,302.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
PREV VISIT NEW AGE 5-11,99383,CPT,510,RC,,,,outpatient,,,363,308.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
GLUCOSE TOLERANCE TEST (GTT),82951,CPT,301,RC,,,,outpatient,,,319,271.15,,70,,18,18,18,1 through 10,percent of total billed charges,,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52.59,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,29.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,29.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,6.91,6.91,6.91,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,44.65,,,,,,,fee schedule,,,85,,33.49,33.49,33.49,1 through 10,percent of total billed charges,,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.87,,,,,,,fee schedule,,12.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,12.87,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,6.84,6.84,8.55,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,6.84,6.84,6.91,34,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,53.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,45.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,13.51,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.44,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.87,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.23,3783,,facility
INHLJ BRNCL CHALLENGE TSTG,95070,CPT,924,RC,,,,outpatient,,,1142,970.7,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,580.28,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1242.26,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,1177.37,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,109.17,,,,,,,fee schedule,,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,394,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,440.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,394,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,486.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1923.65,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1631.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,486.71,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,230,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,229,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,463.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,109.17,3783,,facility
INDIUM IN-111 PENTETREOTIDE,A9572,HCPCS,343,RC,,,,outpatient,,,5875,4993.75,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1700.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,1900.89,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,1700.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,2100.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,2100.99,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,2000.94,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1700.8,3783,,facility
UNLISTED ENDOCRINE PX DX NUC,78099,CPT,341,RC,,,,outpatient,,,1848,1570.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2648,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,1360.63,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 274.00,1464.91,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 295.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,422.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,471.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,422.09,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,521.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2060.81,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1747.96,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,521.41,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,603.39,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,603.39,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,496.58,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,422.09,3783,,facility
"IODINE I-131 IODIDE CAP, DX",A9528,HCPCS,343,RC,,,,outpatient,,,340,289,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,40,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
HEPATITIS B,04705150,CDM,250,RC,,,,inpatient,,,130,110.5,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
VITAL CAPACITY TEST,94150,CPT,460,RC,,,,outpatient,,,528,448.8,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,140.62,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,428.34,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,405.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,151.84,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,135.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,167.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,663.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,562.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,167.82,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,159.83,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,135.86,3783,,facility
HEPATITIS A,04705149,CDM,250,RC,,,,inpatient,,,192,163.2,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,40,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
SMALL IONTOPHORESIS ELECTRO,05211650,CDM,270,RC,,,,outpatient,,,103,87.55,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
CAUTERY SET//,01404206,CDM,272,RC,,,,outpatient,,,105,89.25,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
REMOVE INTRAUTERINE DEVICE,58301,CPT,761,RC,,,,outpatient,,,674,572.9,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,2086,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,1465,,,,,,,fee schedule,,1465,,,,,,,fee schedule,,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,321.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,359.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,321.75,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,397.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1570.9,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,1332.43,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,397.46,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,378.53,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,321.75,3783,,facility
OFF/OP CONSLTJ NEW/EST SF 20,99242,CPT,510,RC,,,,outpatient,,,511,434.35,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,202,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 254.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,65,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 95.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 85.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 415.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 352.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 105.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,135,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment.,,,,0,other,Payer contract is 100.00% of Medicare but standard charge is not recognized under Medicare APC payment. + No services performed during 15-month lookback period,135,3783,,facility
ASSAY OF PHENOBARBITAL,80184,CPT,301,RC,,,,outpatient,,,136,115.6,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,55.2,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,35.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,35.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,42.99,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.3,,,,,,,fee schedule,,14.54,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,15.3,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,16.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,63.5,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,53.86,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,16.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,18.36,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,18.36,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,15.3,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,14.54,3783,,facility
DRUG TEST PRSMV DIR OPT OBS,80305,CPT,301,RC,,,,outpatient,,,41,34.85,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,45.99,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,29.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,29.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,37.82,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.6,,,,,,,fee schedule,,11.97,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,12.6,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,13.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,52.29,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,44.35,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,13.23,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,15.12,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,15.12,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,12.6,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,11.97,3783,,facility
RENAL FUNCTION PANEL,80069,CPT,301,RC,,,,outpatient,,,310,263.5,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,35.49,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,20.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,20.14,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 232.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,30.12,,,,,,,fee schedule,,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.68,,,,,,,fee schedule,,8.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,8.68,,,,,,,fee schedule,,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,9.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,36.02,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,30.55,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,9.11,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,10.42,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,10.42,,,,,,,fee schedule,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,8.68,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,8.25,3783,,facility
"OTH RESP PROC, INDIV",G0238,HCPCS,410,RC,,,,inpatient,,,233,198.05,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,,,,,,,per diem,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable,,,,0,other,Service item reimbursed under IPPS via MS-DRG; separate payment not applicable + No services performed during 15-month lookback period,5834,5834,,facility
BREATHING CAPACITY TEST,94010,CPT,460,RC,,,,outpatient,,,528,448.8,,70,,40,40,40,1 through 10,percent of total billed charges,,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,200.69,,,,,,,fee schedule,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,718.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 268.00,681.25,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 254.00,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,123.42,,,,,,,fee schedule,,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,254.8,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 95.00,227.98,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 85.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,15.15,15.15,15.15,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,15.15,15.15,84.89,1 through 10,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1113.07,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 415.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,944.1,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 352.00,281.62,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 105.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,1249,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,1241,,,,,,,case rate,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,268.21,,,,,,,other,Percent of Medicare Reimbursement + Reimbursement Rate 100.00,123.42,3783,,facility
CERVICAL COLLAR,01404252,CDM,272,RC,,,,outpatient,,,53,45.05,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,77.4,,,,,0,percent of total billed charges,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,44,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 105.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 415.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 215.00 + No services performed during 15-month lookback period,,,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 352.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 105.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,3783,,facility
NORMOSOL M5% DEXT 1000ML/TH,01517390,CDM,260,RC,,,,outpatient,,,124,105.4,,70,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",3783,,,,,,,case rate,,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",1095,,,,,,,case rate,Lesser of + Calculated Reimbursement + Percentage of total billed charges + Reimbursement Rate 100.00,,80,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,75,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,64,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 130.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,,,,,0,,Not paid by the payer plan + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 225.00 + No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,85,,,,,0,percent of total billed charges,No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 95.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 85.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 125.00 + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS.",,,,0,other,"Payer contract is 100.00% of Medicare but standard charge is packaged, not separately payable under Medicare OPPS. + No services performed during 15-month lookback period",,70,,,,,0,percent of total billed charges,Lesser of + Percentage of total billed charges + Reimbursement Rate 100.00 + Calculated Reimbursement + No services performed during 15-month lookback period,,,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00,,,,0,other,Percent of Medicaid Reimbursement + Reimbursement Rate 100.00 + No services performed during 15-month lookback period,,,"Payer contract is 100.00% of Medicare but standard charge is p